Regional practice norms for the care of childhood cancer survivors at risk for cardiomyopathy: A Delphi study

Abstract

Background Treatment‐associated cardiomyopathy is a leading cause of morbidity and mortality for childhood cancer survivors (CCS). As evidence is not available to guide the management of CCS at risk for cardiomyopathy, we aim to describe the collective opinion of regional experts for the care of these patients using a consensus‐based Delphi methodology. Procedure Nineteen physicians from the New England region who care for CCS treated with cardiotoxic therapy (anthracyclines, thoracic radiation) participated in a Delphi panel querying their management approach, using three rounds of anonymous questionnaires formatted as five clinical scenarios. Consensus ≥ 89% agreement. Results The response rate was 100% for the first round and 95% for subsequent rounds. Panelists reached consensus on screening asymptomatic CCS with serial echocardiograms (94%) and electrocardiograms (89%), with some disagreement on frequency during pregnancy (83%). All panelists agreed with exercise promotion, with no restrictions on weight training. Consensus was reached on indications for referrals; cardiology for asymptomatic left ventricular dysfunction (ALVD) (100%) and maternal–fetal medicine for pregnancy (94%). In the scenario of ALVD, there was disagreement on the benefit of additional cardiac testing (50% cardiologists recommended cardiac MRI), and although all panelists endorsed treating with angiotension‐converting enzyme (ACE) inhibitors, most adult cardiologists (75%) also recommended therapy with beta blockers, compared with none of the pediatric cardiologists or primary‐care physicians. Conclusions Despite a lack of evidence to guide the management of CCS at risk for cardiomyopathy, a panel of regional physicians reached consensus on managing most clinical scenarios. A controversial area requiring further study is the medical management of ALVD.

Approaches for monitoring and treating cardiomyopathy among cancer survivors following anthracycline or thoracic radiation treatment

“…The ESC does recommend angiotensin converting enzyme inhibitors or receptor blockers (ACEI/ARB) in combination with beta-blockers in cancer survivors with symptomatic or asymptomatic cardiac dysfunction (unless contraindicated) but do not provide recommendations on other treatments [ 10 ]. A study using Delphi methodology querying physicians for their management approach of these survivors elucidated on this uncertainty, finding agreement in some areas (echocardiogram and ECG screening frequency, exercise promotion, referrals to cardiology, and use of ACEI) and disagreement in other areas (use of other cardiac testing, frequency of screening during pregnancy, and use of beta-blockers) [ 15 ].…”

Management of childhood cancer survivors at risk for thyroid function abnormalities: A Delphi study

“…This consensus‐building approach includes an iterative group survey process to achieve convergence of opinion. It is designed to identify and explore a range of alternative clinical options, to expose and explore underlying assumptions, to capture and evaluate professional opinions spanning a wide range of practice settings, and to work toward clinical consensus 6,7 . This methodology allows the investigation of clinical questions that could not practically be asked in more traditional randomized clinical trials due to the required size and cost of such a trial.…”

Current State of Pediatric Cardio-Oncology: A Review

“…Conversely, the addition of beta blockers varied between the two studies, with one survey reporting a 20% utilization rate and the other study up to 70%. Only one of the studies reported on the use of aldosterone antagonists, at approximately 50% [ 128 , 129 ].…”