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Kesting S, Giordano U, Weil J, McMahon CJ, Albert DC, Berger C, Budts W, Fritsch P, Hidvégi EV, Oberhoffer-Fritz R, Milano GM, Wacker-Gußmann A, Herceg-Čavrak V. Association of European Paediatric and Congenital Cardiology practical recommendations for surveillance and prevention of cardiac disease in childhood cancer survivors: the importance of physical activity and lifestyle changes From the Association of European Paediatric and Congenital Cardiology Working Group Sports Cardiology, Physical Activity and Prevention, Working Group Adult Congenital Heart Disease, Working Group Imaging and Working Group Heart Failure. Cardiol Young 2024; 34:250-261. [PMID: 38174736 DOI: 10.1017/s1047951123004213] [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] [Indexed: 01/05/2024]
Abstract
BACKGROUND Childhood cancer survivors are at increased risk of developing cardiovascular diseases, presenting as the main causes of morbidity and mortality within this group. Besides the usual primary and secondary prevention in combination with screening during follow-up, the modifiable lifestyle factors of physical activity, nutrition, and body weight have not yet gained enough attention regarding potential cardiovascular risk reduction. OBJECTIVE These practical recommendations aim to provide summarised information and practical implications to paediatricians and health professionals treating childhood cancer survivors to reduce the risk of cardiovascular late effects. METHODS The content derives from either published guidelines or expert opinions from Association of European Paediatric and Congenital Cardiology working groups and is in accordance with current state-of-the-art. RESULTS All usual methods of prevention and screening regarding the risk, monitoring, and treatment of occurring cardiovascular diseases are summarised. Additionally, modifiable lifestyle factors are explained, and clear practical implications are named. CONCLUSION Modifiable lifestyle factors should definitely be considered as a cost-effective and complementary approach to already implemented follow-up care programs in cardio-oncology, which can be actively addressed by the survivors themselves. However, treating physicians are strongly encouraged to support survivors to develop and maintain a healthy lifestyle, including physical activity as one of the major influencing factors. This article summarises relevant background information and provides specific practical recommendations on how to advise survivors to increase their level of physical activity.
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Affiliation(s)
- Sabine Kesting
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
- Kinderklinik München Schwabing, Department of Paediatrics and Children's Cancer Research Centre, Department Clinical Medicine, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Ugo Giordano
- Pediatric Cardiac Surgery, Cardiology and Heart/Lung Transplantation Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Jochen Weil
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Dimpna C Albert
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Claire Berger
- Department of Paediatric Haematology and Oncology, University Jean Monnet, University-Hospital of Saint-Etienne, Saint-Etienne, France
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Peter Fritsch
- Private Practice, Institute for Pediatric Cardiology, Graz, Austria
| | | | - Renate Oberhoffer-Fritz
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Giuseppe M Milano
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, Italy
| | - Annette Wacker-Gußmann
- Institute of Preventive Paediatrics, Department Health and Sport Sciences, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
- Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Vesna Herceg-Čavrak
- Faculty of Health Science, Libertas International University, Zagreb, Croatia
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Tsuda T, Davidow K, D'Aloisio G, Quillen J. Surveillance cardiopulmonary exercise testing can risk-stratify childhood cancer survivors: underlying pathophysiology of poor exercise performance and possible room for improvement. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:42. [PMID: 37978571 PMCID: PMC10655267 DOI: 10.1186/s40959-023-00193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Asymptomatic childhood cancer survivors (CCS) frequently show decreased exercise performance. Poor exercise performance may indicate impaired future cardiovascular health. METHODS Cardiopulmonary exercise testing (CPET) was performed in asymptomatic off-treatment CCS (age ≥ 10 years). Patients were divided into Normal and Poor performance groups by %predicted maximum VO2 at 80%. Both peak and submaximal CPET values were analyzed. RESULTS Thirty-eight males (19 Normal, 19 Poor) and 40 females (18 Normal, 22 Poor) were studied. Total anthracycline dosage was comparable among 4 groups. The body mass index (BMI), although normal, and weight were significantly higher in Poor groups. Peak heart rate (HR) and peak respiratory exchange ratio (RER) were comparable in all four groups. Peak work rate (pWR)/kg, peak oxygen consumption (pVO2)/kg, peak oxygen pulse (pOP)/kg, and ventilatory anaerobic threshold (VAT)/kg were significantly lower, whereas heart rate (HR) increase by WR/kg (ΔHR/Δ[WR/kg] was significantly higher in Poor groups. Simultaneously plotting of weight & pVO2 and ΔHR/ΔWR & ΔVO2/ΔHR revealed a distinct difference between the Normal and Poor groups in both sexes, suggesting decreased skeletal muscle mass and decreased stroke volume reserve, respectively, in Poor CCS. The relationship between VAT and pVO2 was almost identical between the two groups in both sexes. Ventilatory efficiency was mildly diminished in the Poor groups. CONCLUSIONS Decreased skeletal muscle mass, decreased stroke volume reserve, and slightly decreased ventilatory efficiency characterize Poor CCS in both sexes. This unique combined CPET analysis provides useful clinical biomarkers to screen subclinical cardiovascular abnormality in CCS and identifies an area for improvement.
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Affiliation(s)
- Takeshi Tsuda
- Nemours Cardiac Center, Nemours Children's Health, 1600 Rockland Rd, Wilmington, DE, 19803, USA.
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, 19107, USA.
| | - Kimberly Davidow
- Nemours Center for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, DE, 19803, USA
| | - Gina D'Aloisio
- Nemours Cardiac Center, Nemours Children's Health, 1600 Rockland Rd, Wilmington, DE, 19803, USA
| | - Joanne Quillen
- Nemours Center for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, DE, 19803, USA
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Engan B, Diab S, Brun H, Raastad T, Torsvik IK, Omdal TR, Ghavidel FZ, Greve G, Ruud E, Edvardsen E, Leirgul E. Systolic myocardial function measured by echocardiographic speckle-tracking and peak oxygen consumption in pediatric childhood cancer survivors-a PACCS study. Front Cardiovasc Med 2023; 10:1221787. [PMID: 37476575 PMCID: PMC10354364 DOI: 10.3389/fcvm.2023.1221787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023] Open
Abstract
Background Cancer therapy-related cardiotoxicity is a major cause of cardiovascular morbidity in childhood cancer survivors. The aims of this study were to investigate systolic myocardial function and its association to cardiorespiratory fitness in pediatric childhood cancer survivors. Methods In this sub-study of the international study "Physical Activity and fitness in Childhood Cancer Survivors" (PACCS), echocardiographic measures of left ventricular global longitudinal strain (LV-GLS) and right ventricular longitudinal strain (RV-LS) were measured in 128 childhood cancer survivors aged 9-18 years and in 23 age- and sex-matched controls. Cardiorespiratory fitness was measured as peak oxygen consumption achieved on treadmill and correlated to myocardial function. Results Mean LV-GLS was reduced in the childhood cancer survivors compared to the controls, -19.7% [95% confidence interval (CI) -20.1% to -19.3%] vs. -21.3% (95% CI: -22.2% to -20.3%) (p = 0.004), however, mainly within normal range. Only 13% of the childhood cancer survivors had reduced LV longitudinal strain z-score. Mean RV-LS was similar in the childhood cancer survivors and the controls, -23.2% (95% CI: -23.7% to -22.6%) vs. -23.3% (95% CI: -24.6% to -22.0%) (p = 0.8). In the childhood cancer survivors, lower myocardial function was associated with lower peak oxygen consumption [correlation coefficient (r) = -0.3 for LV-GLS]. Higher doses of anthracyclines (r = 0.5 for LV-GLS and 0.2 for RV-LS) and increasing time after treatment (r = 0.3 for LV-GLS and 0.2 for RV-LS) were associated with lower myocardial function. Conclusions Left ventricular function, but not right ventricular function, was reduced in pediatric childhood cancer survivors compared to controls, and a lower left ventricular myocardial function was associated with lower peak oxygen consumption. Furthermore, higher anthracycline doses and increasing time after treatment were associated with lower myocardial function, implying that long-term follow-up is important in this population at risk.
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Affiliation(s)
- Britt Engan
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Simone Diab
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Henrik Brun
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
- The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, Oslo, Norway
| | - Truls Raastad
- Department of Sports Medicine, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Ingrid Kristin Torsvik
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Tom Roar Omdal
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | | | - Gottfried Greve
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ellen Ruud
- Department of Pediatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Elisabeth Edvardsen
- Department of Sports Medicine, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Elisabeth Leirgul
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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Cardiopulmonary Exercise Testing Characterizes Silent Cardiovascular Abnormalities in Asymptomatic Pediatric Cancer Survivors. Pediatr Cardiol 2023; 44:344-353. [PMID: 36076098 DOI: 10.1007/s00246-022-02995-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Late-onset cardiovascular complications are serious concerns for pediatric cancer survivors (PCS) including those who are asymptomatic. We investigated whether cardiopulmonary exercise testing (CPET) can delineate the underlying pathophysiology of preclinical cardiovascular abnormalities in PCS. We examined CPET data via cycle ergometer in asymptomatic PCS with normal echocardiogram and age-matched controls. Peak and submaximal parameters were analyzed. Fifty-three PCS and 60 controls were studied. Peak oxygen consumption (VO2), peak work rate (WR), and ventilatory anaerobic threshold (VAT) were significantly lower in PCS than controls (1.86 ± 0.53 vs. 2.23 ± 0.61 L/min, 125 ± 45 vs. 154 ± 46 W, and 1.20 ± 0.35 vs. 1.42 ± 0.43 L/min, respectively; all p < 0.01), whereas peak heart rate (HR) and ventilatory efficiency (a slope of minute ventilation over CO2 production or ∆VE/∆VCO2) were comparable. Peak respiratory exchange ratio (RER) was significantly higher in PCS (p = 0.0006). Stroke volume (SV) reserve was decreased in PCS, indicated by simultaneous higher dependency on HR (higher ∆HR/∆WR) and lower peak oxygen pulse (OP). Twelve PCS with high peak RER (≥ 1.3) revealed lower pVO2 and VAT than the rest of PCS despite higher ventilatory efficiency (lower ∆VE/∆VCO2), suggesting fundamental deficiency in oxygen utilization in some PCS. Poor exercise performance in PCS may be mainly attributed to limited stroke volume reserve, but the underlying pathophysiology is multifactorial. Combined assessment of peak and submaximal CPET parameters provided critical information in delineating underlying exercise physiology of PCS.
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Kincl V, Panovský R, Kepák T, Bajčiová V, Bednárová V, Opatřil L, Máchal J. Assessment of late cardiotoxic effects in patients treated for cancer in childhood. Cancer Med 2022; 11:1763-1768. [PMID: 35166044 PMCID: PMC9041077 DOI: 10.1002/cam4.4564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
Graphical AbstractThe aim was to assess the late cardiotoxic effects in young adults treated for various cancer types in childhood using echocardiography and 24-h ECG Holter monitoring.
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Affiliation(s)
- Vladimír Kincl
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Roman Panovský
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Tomáš Kepák
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Children's Oncology, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Viera Bajčiová
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Children's Oncology, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Veronika Bednárová
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Lukáš Opatřil
- Department of Internal Medicine/Cardiology, St. Anne's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Jan Máchal
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Caru M, Curnier D. The pediatric oncology exercise field speeds up to address important issues regarding chemotherapy-related cardiotoxicity. Front Pediatr 2022; 10:998337. [PMID: 36313894 PMCID: PMC9614334 DOI: 10.3389/fped.2022.998337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/28/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Maxime Caru
- Department of Pediatric, Division of Hematology and Oncology, Penn State College of Medicine, Hershey, PA, United States.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, United States
| | - Daniel Curnier
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, University of Montreal, Montreal, QC, Canada.,Division of Pediatric Hematology and Oncology, Sainte-Justine University Health Center, Research Center, Montreal, QC, Canada
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7
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Exploring pulmonary function and physical function in childhood cancer: A systematic review. Crit Rev Oncol Hematol 2021; 160:103279. [PMID: 33716200 DOI: 10.1016/j.critrevonc.2021.103279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/28/2021] [Accepted: 02/27/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Children with cancer experience pulmonary and physical function side effects from the cancer itself and the medical interventions. This systematic review examines the known relationship between pulmonary function and physical function in childhood cancer and identifies gaps in the literature. METHODS A search of Ovid Medline, CINAHL (EbscoHost) and Embase to identify literature from 2009 to March 2020. RESULTS Fifty-seven studies met inclusion criteria. Thirty-seven studies reported impaired pulmonary function. Incidence of pulmonary dysfunction ranged from 45.5 % to 84.1 %. Eighteen studies reported impaired physical function. Three studies investigated the relationship between pulmonary function and physical function. No studies explored inspiratory muscle strength. CONCLUSION Pulmonary function and physical function are related and frequently impaired in children during and after cancer treatment. A literature gap was found in diaphragm function and its relationship with physical function. Future studies should focus on interventions that target the pulmonary mechanisms impacting physical function.
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8
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Foulkes S, Costello BT, Howden EJ, Janssens K, Dillon H, Toro C, Claus P, Fraser SF, Daly RM, Elliott DA, Conyers R, La Gerche A. Exercise cardiovascular magnetic resonance reveals reduced cardiac reserve in pediatric cancer survivors with impaired cardiopulmonary fitness. J Cardiovasc Magn Reson 2020; 22:64. [PMID: 32892749 PMCID: PMC7487601 DOI: 10.1186/s12968-020-00658-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pediatric cancer survivors are at increased risk of cardiac dysfunction and heart failure. Reduced peak oxygen consumption (peak VO2) is associated with impaired cardiac reserve (defined as the increase in cardiac function from rest to peak exercise) and heart failure risk, but it is unclear whether this relationship exists in pediatric cancer survivors. This study sought to investigate the presence of reduced peak VO2 in pediatric cancer survivors with increased risk of heart failure, and to assess its relationship with resting cardiac function and cardiac haemodynamics and systolic function during exercise. METHODS Twenty pediatric cancer survivors (8-24 years; 10 male) treated with anthracycline chemotherapy ± radiation underwent cardiopulmonary exercise testing to quantify peak VO2, with a value < 85% of predicted defined as impaired peak VO2. Resting cardiac function was assessed using 2- and 3-dimensional echocardiography, with cardiac reserve quantified from resting and peak exercise heart rate, stroke volume index (SVI) and cardiac index (CI) using exercise cardiovascular magnetic resonance (CMR). RESULTS Twelve of 20 survivors (60%) had reduced peak VO2 (70 ± 16% vs. 97 ± 14% of age and gender predicted). There were no differences in echocardiographic or CMR measurements of resting cardiac function between survivors with normal or impaired peak VO2. However, those with reduced peak VO2 had diminished cardiac reserve, with a lesser increase in CI and SVI during exercise (Interaction P < 0.01 for both), whilst the heart rate response was similar (P = 0.71). CONCLUSIONS Whilst exercise intolerance is common among pediatric cancer survivors, it is poorly explained by resting measures of cardiac function. In contrast, impaired exercise capacity is associated with impaired haemodynamics and systolic functional reserve measured during exercise. Consequently, measures of cardiopulmonary fitness and cardiac reserve may aid in early identification of survivors with heightened risk of long-term heart failure.
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Affiliation(s)
- Stephen Foulkes
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Benedict T Costello
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Erin J Howden
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Kristel Janssens
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Hayley Dillon
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Claudia Toro
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steve F Fraser
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - David A Elliott
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Rachel Conyers
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, VIC, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
| | - Andre La Gerche
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
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9
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Abstract
Cardiovascular disease (CVD) is a major competing cause of morbidity and mortality in patients with cancer. Cancer treatment can have detrimental short- and long-term cardiovascular effects. Moreover, cancer patients may have a significant loss in cardiorespiratory fitness, a key CVD risk factor, during and after cancer treatment. Exercise training has emerged as a potential intervention to improve fitness and reduce the risk of CVD in cancer. In this review, we discuss the role of cardiorespiratory fitness to predict cancer and CVD outcomes, as well as explore the impact of exercise training to improve fitness and other key outcomes in patients with cancer. The role of cardio-oncology rehabilitation will also be highlighted.
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Affiliation(s)
- Samuel G Wittekind
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA.
| | - Susan C Gilchrist
- Department of Clinical Cancer Prevention & Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Mizrahi D, Fardell JE, Cohn RJ, Partin RE, Howell CR, Hudson MM, Robison LL, Ness KK, McBride J, Field P, Wakefield CE, Simar D. The 6-minute walk test is a good predictor of cardiorespiratory fitness in childhood cancer survivors when access to comprehensive testing is limited. Int J Cancer 2020; 147:847-855. [PMID: 31800093 PMCID: PMC7269841 DOI: 10.1002/ijc.32819] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/06/2019] [Accepted: 11/20/2019] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease is up to 10 times more likely among childhood cancer survivors compared to siblings. Low cardiorespiratory fitness is a modifiable risk-factor for cardiovascular diseases. Yet, cardiorespiratory fitness is not routinely screened in pediatric oncology, and healthy VO2max cut-points are unavailable. We aimed to predict cardiorespiratory fitness by developing a simple algorithm and establish cut-points identifying survivors' cardiovascular fitness health-risk zones. We recruited 262 childhood cancer survivors (8-18 years old, ≥1-year posttreatment). Participants completed gold-standard cardiorespiratory fitness assessment (Cardiopulmonary Exercise Test [CPET; VO2max ]) and 6-minute walk test (6MWT). Associations with VO2max were included in a linear regression algorithm to predict VO2max , which was then cross-validated. We used Bland-Altman's limits of agreement and Receiver Operating Characteristic curves using FITNESSGRAM's "Healthy Fitness Zones" to identify cut-points for adequate cardiorespiratory fitness. A total of 199 participants (aged 13.7 ± 2.7 years, 8.5 ± 3.5 years posttreatment) were included. We found a strong positive correlation between VO2max and 6MWT distance (r = 0.61, r2 = 0.37, p < 0.001). Our regression algorithm included 6MWT distance, waist-to-height ratio, age and sex to predict VO2max (r = 0.79, r2 = 0.62, p < 0.001). Forty percentages of predicted VO2max values were within ±3 ml/kg/min of measured VO2max . The cut-point for FITNESSGRAM's "health-risk" fitness zone was 39.8 ml/kg/min (males: AUC = 0.88), and 33.5 ml/kg/min (females: AUC = 0.82). We present an algorithm to reasonably predict cardiorespiratory fitness for childhood cancer survivors, using inexpensive measures. This algorithm has useful clinical application, particularly when CPET is unavailable. Our algorithm has the potential to assist clinicians to identify survivors below the cut-points with increased cardiovascular disease-risk, to monitor and refer for tailored interventions with exercise specialists.
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Affiliation(s)
- David Mizrahi
- School of Medical Sciences, UNSW Sydney, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia
| | - Joanna E. Fardell
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia
- School of Women’s and Children’s Health, UNSW Sydney, Australia
| | - Richard J. Cohn
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia
- School of Women’s and Children’s Health, UNSW Sydney, Australia
| | - Robyn E. Partin
- Departments of Epidemiology and Cancer Control, United States of America
| | - Carrie R. Howell
- Departments of Epidemiology and Cancer Control, United States of America
| | - Melissa M. Hudson
- Departments of Epidemiology and Cancer Control, United States of America
- Oncology, St. Jude Children’s Research Hospital, Memphis, United States of America
| | - Leslie L. Robison
- Departments of Epidemiology and Cancer Control, United States of America
| | - Kirsten K. Ness
- Departments of Epidemiology and Cancer Control, United States of America
| | - Jamie McBride
- Respiratory Medicine, Sydney Children’s Hospital, Sydney, Australia
| | - Penelope Field
- Respiratory Medicine, Sydney Children’s Hospital, Sydney, Australia
| | - Claire E. Wakefield
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia
- School of Women’s and Children’s Health, UNSW Sydney, Australia
| | - David Simar
- School of Medical Sciences, UNSW Sydney, Australia
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Mizrahi D, Wakefield CE, Simar D, Ha L, McBride J, Field P, Cohn RJ, Fardell JE. Barriers and enablers to physical activity and aerobic fitness deficits among childhood cancer survivors. Pediatr Blood Cancer 2020; 67:e28339. [PMID: 32386117 DOI: 10.1002/pbc.28339] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Physical activity and aerobic fitness are modifiable risk factors for cardiovascular disease (CVD) after childhood cancer. How survivors engage in physical activity remains unclear, potentially increasing CVD risk. We assessed survivors' physical activity levels, barriers and enablers, fitness, and identified predictors of fitness and physical activity stage of change. METHODS Childhood cancer survivors (CCS; 8-18 years old) ≥1 year post-treatment were assessed for aerobic fitness (6-min walk test), used to extrapolate VO2max , and body composition (InBody 570). Survivors self-reported physical activity to determine stage of change (Patient-Centered Assessment and Counselling for Exercise). Physical activity and fitness were compared with guidelines and CVD-risk cut-points (VO2max < 42 mL/kg/min: males; VO2max < 35 mL/kg/min: females). Multiple regression and mediator-moderator analysis were used to identify fitness predictors and stage of change. RESULTS One hundred two survivors (12.8 ± 3.3 years) participated (46% acute lymphoblastic leukaemia). Forty percent of males (VO2max = 43.3 ± 6.3 mL/kg/min) and 28% of females (VO2max = 36.5 ± 5.9 mL/kg/min) were in the CVD-risk category, while 25% met physical activity guidelines. Most prevalent physical activity barriers were fatigue (52%), preferring television instead of exercise (38%), and lacking time (34%). Predictive factors for reduced fitness included being older, female, higher waist-to-height ratio, higher screen time, and moderated by lower physical activity (r2 = 0.91, P < .001). Survivors with higher physical activity stage of change were male, lower body fat percentage, lower screen time, and lived with both parents (r = 0.42, P = .003). CONCLUSION Aerobic fitness and physical activity of CCS is low compared with population norms, potentially increasing CVD risk. Addressing physical activity barriers and enablers, including reducing screen time, could promote regular physical activity, reducing CVD risk.
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Affiliation(s)
- David Mizrahi
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia.,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Claire E Wakefield
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia.,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - David Simar
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia
| | - Lauren Ha
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia.,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - James McBride
- Respiratory Medicine, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Penelope Field
- Respiratory Medicine, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Richard J Cohn
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia.,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Joanna E Fardell
- UNSW Medicine, UNSW, Sydney, New South Wales, Australia.,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
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12
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Foulkes S, Claessen G, Howden EJ, Daly RM, Fraser SF, La Gerche A. The Utility of Cardiac Reserve for the Early Detection of Cancer Treatment-Related Cardiac Dysfunction: A Comprehensive Overview. Front Cardiovasc Med 2020; 7:32. [PMID: 32211421 PMCID: PMC7076049 DOI: 10.3389/fcvm.2020.00032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022] Open
Abstract
With progressive advancements in cancer detection and treatment, cancer-specific survival has improved dramatically over the past decades. Consequently, long-term health outcomes are increasingly defined by comorbidities such as cardiovascular disease. Importantly, a number of well-established and emerging cancer treatments have been associated with varying degrees of cardiovascular injury that may not emerge until years following the completion of cancer treatment. Of particular concern is the development of cancer treatment related cardiac dysfunction (CTRCD) which is associated with an increased risk of heart failure and high risk of morbidity and mortality. Early detection of CTRCD appears critical for preventing long-term cardiovascular morbidity in cancer survivors. However, current clinical standards for the identification of CTRCD rely on assessments of cardiac function in the resting state. This provides incomplete information about the heart's reserve capacity and may reduce the sensitivity for detecting sub-clinical myocardial injury. Advances in non-invasive imaging techniques have enabled cardiac function to be quantified during exercise thereby providing a novel means of identifying early cardiac dysfunction that has proved useful in several cardiovascular pathologies. The purpose of this narrative review is (1) to discuss the different non-invasive imaging techniques that can be used for quantifying different aspects of cardiac reserve; (2) discuss the findings from studies of cancer patients that have measured cardiac reserve as a marker of CTRCD; and (3) highlight the future directions important knowledge gaps that need to be addressed for cardiac reserve to be effectively integrated into routine monitoring for cancer patients exposed to cardiotoxic therapies.
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Affiliation(s)
- Stephen Foulkes
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia.,Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Guido Claessen
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Erin J Howden
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Robin M Daly
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Steve F Fraser
- School of Exercise and Nutrition Sciences, Institute of Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Andre La Gerche
- Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
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13
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Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association. Circulation 2020; 139:e997-e1012. [PMID: 30955352 DOI: 10.1161/cir.0000000000000679] [Citation(s) in RCA: 214] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.
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14
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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.
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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
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15
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Ness KK, Plana JC, Joshi VM, Luepker RV, Durand JB, Green DM, Partin RE, Santucci AK, Howell RM, Srivastava DK, Hudson MM, Robison LL, Armstrong GT. Exercise Intolerance, Mortality, and Organ System Impairment in Adult Survivors of Childhood Cancer. J Clin Oncol 2019; 38:29-42. [PMID: 31622133 DOI: 10.1200/jco.19.01661] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Exercise intolerance, associated with heart failure and death in general populations, is not well studied in survivors of childhood cancer. We examined prevalence of exercise intolerance in survivors exposed or not to cardiotoxic therapy, and associations among organ system function, exercise intolerance, and mortality. METHODS Participants consisted of 1,041 people who had survived cancer ≥ 10 years (and had or did not have exposure to anthracyclines and/or chest-directed radiation) and 285 control subjects. Exercise intolerance was defined as peak oxygen uptake < 85% predicted from maximal cardiopulmonary exercise testing; organ functions were ascertained with imaging or clinical testing. Multivariable regression of the data was performed to compare exercise capacity between survivors exposed or unexposed to cardiotoxic therapy and control subjects, and to evaluate associations between treatment and organ function, and organ function and exercise intolerance. Propensity score methods in time-to-event analyses evaluated associations between exercise intolerance and mortality. RESULTS Survivors (mean age ± standard deviation [SD], 35.6 ± 8.8 years) had lower mean (± SD) peak oxygen uptake (exposed: 25.74 ± 8.36 mL/kg/min; unexposed: 26.82 ± 8.36 mL/kg/min) than did control subjects (32.69 ± 7.75 mL/kg/min; P for all < .001). Exercise intolerance was present in 63.8% (95% CI, 62.0% to 65.8%) of exposed survivors, 55.7% (95% CI, 53.2% to 58.2%) of unexposed survivors, and 26.3% (95% CI, 24.0% to 28.3%) of control subjects, and was associated with mortality (hazard ratio, 3.9; 95% CI, 1.09 to 14.14). Global longitudinal strain (odds ratio [OR], 1.71; 95% CI, 1.11 to 2.63), chronotropic incompetence (OR, 3.58; 95% CI, 1.75 to 7.31); forced expiratory volume in 1 second < 80% (OR, 2.59; 95% CI, 1.65 to 4.09), and 1 SD decrease in quadriceps strength (OR, 1.49; 95% CI, 1.23 to 1.82) were associated with exercise intolerance. Ejection fraction < 53% was not associated with exercise intolerance. CONCLUSION Exercise intolerance is prevalent among childhood cancer survivors and associated with all-cause mortality. Treatment-related cardiac (detected by global longitudinal strain), autonomic, pulmonary, and muscular impairments increased risk. Survivors with impairments may require referral to trained specialists to learn to accommodate specific deficits when engaging in exercise.
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Affiliation(s)
| | | | - Vijaya M Joshi
- University of Tennessee Health Science Center, Memphis, TN
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16
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Long TM, Marsh CE, Dembo LG, Watson P, Wallman KE, Walwyn TS, Choong CS, Naylor LH. Early markers of cardiovascular injury in childhood leukaemia survivors treated with anthracycline chemotherapy. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2019; 5:11. [PMID: 32154017 PMCID: PMC7048057 DOI: 10.1186/s40959-019-0047-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/24/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading non-malignant cause of death in childhood cancer survivors. Heightened risk of CVD is often attributable to treatment with anthracycline chemotherapy. Anthracycline-mediated cardiac injury may lie latent for years following cessation of treatment and is therefore often not detected until disease is advanced and aggressive therapy is required. Symptomatic CVD may be preceded by subclinical cardiac and vascular dysfunction. This study aimed to determine whether such dysfunction could be detected in healthy, anthracycline-treated survivors of childhood leukaemia. METHODS Cardiac magnetic resonance imaging (cMRI) with late gadolinium enhancement and endothelial function were used to characterise pre-clinical stages of CVD. Twenty-two long-term (>5 years survival; age 21 ± 3 years) childhood leukaemia survivors were assessed. All survivors were asymptomatic and had normal resting echocardiography. To exclude potential confounding effects of radiotherapy, no survivors had received this treatment. Twenty-two similarly aged (25 ± 3 years) gender-matched controls were recruited for comparison. RESULTS Left ventricular ejection fraction was lower in the survivors (55.0 ± 4.6%) compared to the controls (59.4 ± 6.2%; p = 0.010). Further, five survivors (23%) had clinically reduced (<50%) left ventricular ejection fraction. Normalised left ventricular end systolic volume was augmented in survivors (40.0 ± 9.1 mL·m2 vs. 34.5 ± 7.5 mL·m2; p = 0.038). Cardiac MRI did not show any late gadolinium enhancement. High resolution, ultrasound-derived flow mediated dilation was impaired in survivors (6.7 ± 2.1% vs. 8.60 ± 1.91%, p = 0.005). CONCLUSIONS We detected subclinical changes in cardiovascular structure and function indicative of early disease in anthracycline-treated childhood leukaemia survivors with normal echocardiography. Early detection and characterisation of underlying disease allows for timely intervention and improved outcomes in this at-risk population.
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Affiliation(s)
- Treya M. Long
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
| | - Channa E. Marsh
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
| | - Lawrence G. Dembo
- Envision Medical Imaging, 178-190 Cambridge St, Wembley, WA 6014 Australia
- Advanced Heart Failure Unit and Cardiac Transplant Service of Western Australia, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA 6150 Australia
| | - Philip Watson
- Envision Medical Imaging, 178-190 Cambridge St, Wembley, WA 6014 Australia
| | - Karen E. Wallman
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
| | - Thomas S. Walwyn
- School of Medicine: Paediatrics, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
- Department of Haematology and Oncology, Perth Children’s Hospital, 15 Hospital Ave, Nedlands, WA 6009 Australia
| | - Catherine S. Choong
- School of Medicine: Paediatrics, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
- Department of Endocrinology, Perth Children’s Hospital, 15 Hospital Ave, Nedlands, WA 6009 Australia
| | - Louise H. Naylor
- School of Human Sciences: Exercise and Sport Science, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia
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17
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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.
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18
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Masopustová A, Jehlička P, Huml M, Votava T, Trefil L, Kreslová M, Sýkora J. Plethysmographic and biochemical markers in the diagnosis of endothelial dysfunction in pediatric acute lymphoblastic leukemia survivors - new applications. Physiol Res 2018; 67:903-909. [PMID: 30204466 DOI: 10.33549/physiolres.933754] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) and its treatment are associated with endothelial dysfunction (ED) and increased cardiovascular risk in adulthood. There are no data on ED in children after successful treatment of ALL. We aimed to assess new ED in these children using the plethysmographic reactive hyperemia index (RHI) and biomarkers that are known to be related to ED. In all, 22 children (mean 15.6 years), after successful treatment of ALL, and 18 healthy subjects were included in this prospective study. RHI, plasma concentrations of asymmetric dimethyl arginine (ADMA), high-sensitive CRP (hsCRP) and E-selectin were measured in all children. RHI values were significantly lower in ALL patients when compared with healthy controls (p<0.05). hsCRP was significantly increased in ALL patients compared with the control group (p<0.001). E-selectin plasma levels were higher in ALL patients as compared to healthy controls (p=0.05). This is the first study that combines both plethysmographic and biochemical methods to assess ED in ALL survivors. Significantly decreased RHI with elevated plasma concentrations of biochemical markers imply a possible association with premature ED in ALL patients. The combined diagnostic approach seems to be a valuable tool for more accurate detection of ED and preventive cardiovascular management in these patients.
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Affiliation(s)
- A Masopustová
- Department of Pediatrics, Faculty of Medicine in Pilsen, Faculty Hospital, Charles University in Prague, Pilsen, Czech Republic.
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19
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Cardiopulmonary Aerobic Fitness Assessment During Maximal and Submaximal Exercise Testing in Pediatric Oncology Patients After Chemotherapy. Am J Clin Oncol 2018; 41:1058-1061. [PMID: 29356733 DOI: 10.1097/coc.0000000000000422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The cardiopulmonary exercise test (CPET) is a valuable tool to assess cardiopulmonary exercise capacity in pediatric oncology patients after chemotherapy. In addition, few studies on the utility of submaximal testing have been performed, which could be important as some patients are unable to complete a maximal effort test secondary to deconditioning by both disease and treatment. MATERIALS AND METHODS We performed a retrospective chart review of pediatric cancer patients exposed to chemotherapy from 1992 to 2013 who underwent CPET with cycle ergometry (n=27). The study patients were compared with age-matched, sex-matched, and size-matched normal controls. The submaximal measure recorded was the oxygen consumption (VO2)@respiratory exchange ratio (RER) 1.0 during a maximal effort test. RESULTS The chemotherapy group demonstrated significantly lower exercise time (9.2±3.6 vs. 11.4±3.8; P=0.008), total work capacity (4914.4±3290.3 vs. 7664.4±4289.5; P=0.004), systolic blood pressure at peak exercise (162.9±23.2 vs. 177.3±23.8; P=0.01), indexed peak VO2 (33.9±6.9 vs. 40.0±6.3; P=0.001), and indexed peak oxygen pulse (6.1±1.3 vs. 7.0±1.5; P=0.004)). For the submaximal outcome measured, 11/27 of the chemotherapy patients had VO2@RER 1.0 values <-2 SD from the mean compared with 0/27 control patients. CONCLUSIONS Pediatric patients exposed to chemotherapy have impaired cardiopulmonary exercise capacity. The VO2@RER 1.0 in chemotherapy patients suggests that this may be a reliable submaximal measure in this population. IMPLICATIONS FOR CANCER SURVIVORS This study demonstrates that the CPET can be used in pediatric cancer survivors with prior exposure to chemotherapy to demonstrate impaired cardiopulmonary exercise tolerance, which is demonstrated on submaximal and maximal effort testing.
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20
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Yildiz Kabak V, Calders P, Duger T, Mohammed J, van Breda E. Short and long-term impairments of cardiopulmonary fitness level in previous childhood cancer cases: a systematic review. Support Care Cancer 2018; 27:69-86. [DOI: 10.1007/s00520-018-4483-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023]
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21
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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.
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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.
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22
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Bassareo PP, Monte I, Romano C, Deidda M, Piras A, Cugusi L, Coppola C, Galletta F, Mercuro G. Cardiotoxicity from anthracycline and cardioprotection in paediatric cancer patients. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e55-e63. [PMID: 27755243 DOI: 10.2459/jcm.0000000000000375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Notwithstanding the steady progress in survival rates of children and adolescents suffering from cancer, the benefits associated with chemotherapy do not come without risks involving multiple organs and systems, including the cardiovascular apparatus. Anthracyclines-often administered in combination with radiation therapy and/or surgery-are the most used chemotherapeutic compounds in order to treat tumours and blood malignancies even in paediatric age. Being an important side-effect of anthracyclines, carduitoxicity may limit their efficacy during the treatment and induce long-term sequelae, observed even many years after therapy completion. The purpose of this review was to perform an overview about all the possible strategies to prevent and/or limit the anthracyclines adverse side-effects for the cardiovascular system in childhood cancer survivors.
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Affiliation(s)
- Pier P Bassareo
- aDepartment of Medical Sciences 'Mario Aresu', University of Cagliari bGeneral Surgery and Medical-Surgery Specialities Department, University of Catania cDivision of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale'-IRCCS, Naples, Italy
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23
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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 2016; 312:H213-H222. [PMID: 27923793 DOI: 10.1152/ajpheart.00646.2016] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [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.
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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
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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.
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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
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25
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A Review of Cardiorespiratory Fitness in Adolescent and Young Adult Survivors of Childhood Cancer: Factors that Affect its Decline and Opportunities for Intervention. J Adolesc Young Adult Oncol 2016; 5:8-15. [DOI: 10.1089/jayao.2015.0031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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26
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Ehrhardt MJ, Fulbright JM, Armenian SH. Cardiomyopathy in Childhood Cancer Survivors: Lessons from the Past and Challenges for the Future. Curr Oncol Rep 2016; 18:22. [DOI: 10.1007/s11912-016-0510-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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27
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Christiansen JR, Kanellopoulos A, Lund MB, Massey R, Dalen H, Kiserud CE, Ruud E, Aakhus S. Impaired exercise capacity and left ventricular function in long-term adult survivors of childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2015; 62:1437-43. [PMID: 25832752 DOI: 10.1002/pbc.25492] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/03/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for late cardiotoxic effects of cancer treatment, but conflicting evidence exists on the effects of anthracyclines on left ventricular (LV) diastolic function and exercise capacity. PROCEDURE We performed a cross-sectional study with comprehensive echocardiography in 138 adult survivors of childhood ALL, median 23.4 years after diagnosis. Pulsed tissue Doppler measurements of early diastolic mitral annular velocities (e') were used for the assessment of diastolic function, and compared to 138 matched controls. Of the survivors, 133 also performed ergospirometry measuring peak oxygen uptake (VO2 max). Associations between cancer treatment, LV function, and VO2 max were analyzed. RESULTS The survivor group had lower e' values than controls (e' septal 11.0 vs. 12.6 cm/s, P < 0.001), but the difference was confined to the subgroup of anthracycline treated survivors (median cumulative dose 120 mg/m(2) ). Anthracycline exposure was inversely correlated with e' (regression coefficient -1.581, P=0.009). Reduced VO2 max/kg occurred in 47% of the survivors, but more often in anthracycline treated survivors (56%) than anthracycline naïve survivors (17%, P<0.001). Anthracycline exposure was inversely correlated with VO2 max/kg (regression coefficient -3.084, P = 0.05 in multivariate analysis). Furthermore, associations were observed between measures of LV function and VO2 max/kg, and e' was the best predictor of VO2 max/kg (standardized coefficient 0.355, P < 0.001 in multivariate analysis). CONCLUSIONS Adult survivors of childhood ALL have increased risk for impaired LV diastolic function and impaired exercise capacity, both associated with previous anthracycline exposure. Furthermore, there is an association between LV diastolic function and exercise capacity.
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Affiliation(s)
- Jon R Christiansen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Medicine, Innlandet Hospital Trust, Elverum, Norway
| | - Adriani Kanellopoulos
- Department of Pediatric Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - May B Lund
- Department of Respiratory Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Richard Massey
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Håvard Dalen
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cecilie E Kiserud
- National Resource Centre for Late Effects after Cancer Treatment, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Ellen Ruud
- Department of Pediatric Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Endothelial health in childhood acute lymphoid leukemia survivors: pilot evaluation with peripheral artery tonometry. J Pediatr Hematol Oncol 2015; 37:117-20. [PMID: 24577544 PMCID: PMC4145053 DOI: 10.1097/mph.0000000000000122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Childhood cancer survivors are a growing population at risk for poor cardiac outcomes. Acute lymphoid leukemia (ALL) survivors are among those at increased risk of cardiovascular complications. Early identification of impaired vascular health may allow for interventions to improve these outcomes. The purpose of this study was to evaluate vascular health using peripheral artery tonometry in ALL survivors and compare results with healthy siblings. PROCEDURE Sixteen ALL survivor, healthy sibling pairs, aged 8 to 20 years, were evaluated for vascular health and cardiovascular risk factors (body mass index, central adiposity, blood pressure, and fitness). One-tailed paired t test was used to compare the groups. RESULTS Survivors were similar to siblings in cardiovascular risk measures but had poorer vascular health as measured by reactive hyperemia index (survivor RHI 1.54 vs. sibling 1.77; P=0.0474). CONCLUSION This study reveals that even among survivors who are comparable to their healthy siblings in other traditional cardiovascular risks, there is evidence of poorer vascular health.
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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.
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Affiliation(s)
- A Blythe Ryerson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJE, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LCM. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2015; 16:e123-36. [PMID: 25752563 PMCID: PMC4485458 DOI: 10.1016/s1470-2045(14)70409-7] [Citation(s) in RCA: 358] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, USA.
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Ming Hui Chen
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Dwyer
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Paul C Nathan
- The Hospital for Sick Children and the University of Toronto, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Wim J E Tissing
- Division of Pediatric Oncology and Pediatric Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sadhna Shankar
- Division of Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Elske Sieswerda
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and University of Newcastle, Newcastle upon Tyne, UK
| | - Julia Steinberger
- Department of Pediatrics, Division of Cardiology, University of Minnesota Amplatz Childrens' Hospital, Minneapolis, MN, USA
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena van der Pal
- Department of Pediatric Oncology and Medical Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - W Hamish Wallace
- Department of Hematology/Oncology, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
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Leger K, Slone T, Lemler M, Leonard D, Cochran C, Bowman WP, Bashore L, Winick N. Subclinical cardiotoxicity in childhood cancer survivors exposed to very low dose anthracycline therapy. Pediatr Blood Cancer 2015; 62:123-7. [PMID: 25176022 DOI: 10.1002/pbc.25206] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/10/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Subclinical cardiotoxicity occurs in childhood cancer survivors following moderate and high anthracycline doses. However, less is known about the subclinical changes in left ventricular (LV) structure that occur after very low anthracycline doses of ≤ 100 mg/m(2). This study was designed to assess LV function and key structural parameters following very low doses of anthracycline. PROCEDURE Conventional 2-dimensional echocardiograms with Doppler were obtained in 91 survivors of childhood cancer exposed to ≤ 100 mg/m(2), an average of 9.8 years from diagnosis. LV structural measurements were converted into Z-scores. The Z-score distributions were compared to those of the normal population. Diastolic and systolic function were quantified. RESULTS The cohort demonstrated a decreased posterior wall thickness (mean Z-score -1.01) and mildly decreased LV end diastolic (mean Z-score -0.85) and systolic (mean Z-score -0.84) dimensions compared to the normal population (P < 0.001). Further, 28% of patients (n = 25) had abnormal LV posterior wall thickness, ≥ 2 standard deviations below the mean (Z-score ≤ -2). There were no patients with diastolic dysfunction or symptomatic systolic dysfunction, however four patients demonstrated abnormal SF ≤ 28%. CONCLUSIONS A significant proportion of patients exposed to very low doses of anthracycline demonstrate subclinical abnormalities in LV structure, despite the absence of radiation or other risk factors. While we cannot say whether these structural changes will result in clinically significant cardiac disease, the reported progressive nature of these findings raises concern that there may truly be no safe dose of anthracycline.
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Affiliation(s)
- Kasey Leger
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, University of Washington, Seattle, Washington
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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: 360] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Tham EB, Haykowsky MJ, Chow K, Spavor M, Kaneko S, Khoo NS, Pagano JJ, Mackie AS, Thompson RB. Diffuse myocardial fibrosis by T1-mapping in children with subclinical anthracycline cardiotoxicity: relationship to exercise capacity, cumulative dose and remodeling. J Cardiovasc Magn Reson 2013; 15:48. [PMID: 23758789 PMCID: PMC3688348 DOI: 10.1186/1532-429x-15-48] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 05/16/2013] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The late cardiotoxic effects of anthracycline chemotherapy influence morbidity and mortality in the growing population of childhood cancer survivors. Even with lower anthracycline doses, evidence of adverse cardiac remodeling and reduced exercise capacity exist. We aim to examine the relationship between cardiac structure, function and cardiovascular magnetic resonance (CMR) tissue characteristics with chemotherapy dose and exercise capacity in childhood cancer survivors. METHODS Thirty patients (15 ± 3 years), at least 2 years following anthracycline treatment, underwent CMR, echocardiography, and cardiopulmonary exercise testing (peak VO(2)). CMR measured ventricular function, mass, T(1) and T(2) values, and myocardial extracellular volume fraction, ECV, a measure of diffuse fibrosis based on changes in myocardial T1 values pre- and post-gadolinium. Cardiac function was also assessed with conventional and speckle tracking echocardiography. RESULTS Patients had normal LVEF (59 ± 7%) but peak VO(2) was 17% lower than age-predicted normal values and were correlated with anthracycline dose (r = -0.49). Increased ECV correlated with decreased mass/volume ratio (r = -0.64), decreased LV wall thickness/height ratio (r = -0.72), lower peak VO(2)(r = -0.52), and higher cumulative dose (r = 0.40). Echocardiographic measures of systolic and diastolic function were reduced compared to normal values (p < 0.01), but had no relation to ECV, peak VO(2) or cumulative dose. CONCLUSIONS Myocardial T1 and ECV were found to be early tissue markers of ventricular remodeling that may represent diffuse fibrosis in children with normal ejection fraction post anthracycline therapy, and are related to cumulative dose, exercise capacity and myocardial wall thinning.
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Affiliation(s)
- Edythe B Tham
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology, Stollery Children’s Hospital, 4C2 Walter C Mackenzie Centre, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
| | - Mark J Haykowsky
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kelvin Chow
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Maria Spavor
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Sachie Kaneko
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Nee S Khoo
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Joseph J Pagano
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
| | - Andrew S Mackie
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Richard B Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
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Carver JR, Szalda D, Ky B. Asymptomatic cardiac toxicity in long-term cancer survivors: defining the population and recommendations for surveillance. Semin Oncol 2013; 40:229-38. [PMID: 23540748 PMCID: PMC3686285 DOI: 10.1053/j.seminoncol.2013.01.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Advances in the treatment of pediatric and adult cancer have reduced the mortality rates from these disorders and have led to an ever-increasing population of long-term survivors. Chemotherapy and radiotherapy may cause premature cardiac disease that may be asymptomatic or symptomatic. All patients exposed to chemotherapy with cardiotoxic potential or chest radiotherapy have stage A heart failure and the goal of surveillance and treatment is to prevent progression to stages B-D. Screening strategies, including the use of biomarkers, echocardiography, and expert opinion surveillance and treatment recommendations, are presented.
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Affiliation(s)
- Joseph R Carver
- Cardio-oncology in the Division of Cardiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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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.
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de Ville de Goyet M, Moniotte S, Brichard B. Cardiotoxicity of childhood cancer treatment: update and current knowledge on long-term follow-up. Pediatr Hematol Oncol 2012; 29:395-414. [PMID: 22732022 DOI: 10.3109/08880018.2012.694092] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Therapeutic advances in paediatric oncology allowed increasing numbers of children to survive until adulthood. However, chemotherapy and radiotherapy are potentially cardiotoxic and contribute to a significant morbidity and mortality, cardiovascular events remaining the leading cause of death among survivors. This review summarizes the physiopathology of treatment-related cardiovascular diseases, their incidence, and the risk factors associated with each specific therapy. Few studies have investigated the cardiac outcomes of adult surviving from childhood cancers but all demonstrated a substantial risk for late cardiac effects. Cardiovascular monitoring, prevention, and early detection of cardiac dysfunction are, therefore, the keystones of an improved long-term outcome.
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology and Oncology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Hayward R, Lien CY, Jensen BT, Hydock DS, Schneider CM. Exercise training mitigates anthracycline-induced chronic cardiotoxicity in a juvenile rat model. Pediatr Blood Cancer 2012; 59:149-54. [PMID: 22052855 DOI: 10.1002/pbc.23392] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 09/20/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Childhood cancer survivors are at greater risk of cardiovascular complications once they reach adulthood. Anthracyclines may be a major contributor to these delayed-onset complications, yet their use continues because of favorable clinical outcomes. Exercise has been shown to protect against anthracycline cardiotoxicity, yet it is unclear whether exercise can protect against delayed-onset cardiotoxicity when treatment is initiated in childhood. The aim of the present study was to determine if exercise training provides cardioprotection in a juvenile rat model of delayed-onset anthracycline cardiotoxicity. PROCEDURE At 25 days of age, male Sprague-Dawley rat pups were subjected to a treatment regimen with the anthracycline doxorubicin (DOX). Pups received DOX at 2 mg/kg on 7 consecutive days (cumulative dose 14 mg/kg) or saline as a control. At the time DOX treatment began, pups remained sedentary or were allowed to voluntarily exercise. Ten weeks after the initiation of exercise, cardiac function was assessed both in vivo and ex vivo. RESULTS DOX treatment stunted normal growth and significantly impaired cardiac function. While voluntary exercise did not offset changes in the growth curve, it did provide significant cardioprotection against DOX-induced cardiotoxicity. CONCLUSIONS Exercise training, initiated at the time treatment begins, can protect against delayed-onset anthracycline-induced cardiotoxicity in adult rats that were treated with anthracyclines as juveniles.
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Affiliation(s)
- Reid Hayward
- School of Sport and Exercise Science and the Rocky Mountain Cancer Rehabilitation Institute, University of Northern Colorado, Greeley, Colorado 80639, USA.
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Fulbright JM. Review of cardiotoxicity in pediatric cancer patients: during and after therapy. Cardiol Res Pract 2011; 2011:942090. [PMID: 21637324 PMCID: PMC3102324 DOI: 10.4061/2011/942090] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 01/31/2011] [Accepted: 03/17/2011] [Indexed: 01/12/2023] Open
Abstract
With the improvement in survival from childhood cancer, late effects of therapy are becoming more apparent. Cardiac disease, one of these late effects, has a significant impact on the life of survivors of childhood cancers. Most survivors are followed by primary care doctors and adult subspecialists after they have graduated from pediatric centers. Since much of the cardiac toxicity of therapy occurs years off of therapy, it is important for these physicians to be aware of how to monitor survivors for the development of cardiac toxicities. In this paper we will discuss the incidence of cardiac disease during treatment and in survivors, what treatment modalities contribute to its development and modalities utilized to screen for cardiac disease. Recommendations for posttherapy monitoring will be emphasized.
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Affiliation(s)
- Joy M. Fulbright
- Division of Pediatric Hematology/Oncology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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