Implications of cancer prior to and after heart transplantation

Abstract

Cancer and cardiovascular disease share many risk factors. Due to improved survival of patients with cancer, the cohort of cancer survivors with heart failure referred for heart transplantation (HT) is growing. Specific considerations include time interval between cancer treatment and HT, risk for recurrence and risk for de novo malignancy (dnM). dnM is an important cause of post-HT morbidity and mortality, with nearly a third diagnosed with malignancy by 10 years post-HT. Compared with the age-matched general population, HT recipients have an approximately 2.5-fold to 4-fold increased risk of developing cancer. HT recipients with prior malignancy show variable cancer recurrence rates, depending on years in remission before HT: 5% recurrence if >5 years in remission, 26% recurrence if 1–5 years in remission and 63% recurrence if <1 year in remission. A myriad of mechanisms influence oncogenesis following HT, including reduced host immunosurveillance from chronic immunosuppression, influence of oncogenic viruses, and the cumulative intensity and duration of immunosuppression. Conversely, protective factors include acyclovir prophylaxis, use of proliferation signal inhibitors (PSI) and female gender. Management involves reducing immunosuppression, incorporating a PSI for immunosuppression and heightened surveillance for allograft rejection. Cancer treatment, including immunotherapy, may be cardiotoxic and lead to graft failure or rejection. Additionally, there exists a competing risk to reduce immunosuppression to improve cancer outcomes, which may increase risk for rejection. A multidisciplinary cardio-oncology team approach is recommended to optimise care and should include an oncologist, transplant cardiologist, transplant pharmacist, palliative care, transplant coordinator and cardio-oncologist.

Development and Validation of a Model to Predict Malignancy Within the First Year After Adult Heart Transplantation

“…1,11 Although a prior history of malignancy is known to predict future development, 2 the risk is higher based on the time in remission prior to transplant. 1,27 This level of detail was not available in the SRTR and was, therefore, not accounted for in our model. Our model also suggested that increasing recipient age at transplant has a strong relationship with posttransplant malignancy.…”

The ABC of Heart Transplantation—Part 1: Indication, Eligibility, Donor Selection, and Surgical Technique

“…Improved survival of cancer patients has led to an increase in the cohort of patients with a history of malignancy undergoing HT in recent years [ 45 ]. For these patients, the risk of recurrence or de novo cancer has increased about 2.5–4-times compared with the general population of the same age [ 46 , 47 ].…”

Early Implementation of Palliative and Supportive Care in Hepatocellular Carcinoma

“…Most organ specific malignancies are a contraindication for transplantation, and non-liver solid malignancy is a contraindication for 5 years for liver transplantation. It should be noted that there have been recent suggestions to use a more tailored risk assessment for these patients [123][124][125]. This additional…”

“…It should be noted that there have been recent suggestions to use a more tailored risk assessment for these patients. [115][116][117] This additional therapeutic option often causes significant uncertainty in the clinical prognosis of HCC patients. Since patients are potentially curative but have significant symptom burden, there is poor acceptability of palliative and supportive care intervention due to clinician belief around the utilization of these services while patients are still undergoing "active" treatment.…”