The landscape of cardiovascular care in pediatric cancer patients and survivors: a survey by the ACC Pediatric Cardio-Oncology Work Group

Abstract

Objective: To enhance the understanding of cardiovascular care delivery in childhood cancer patients and survivors. Study design: A 20-question survey was created by the Pediatric Cardio-oncology Work Group of the American College of Cardiology (ACC) Cardio-oncology Section to assess the care, management, and surveillance tools utilized to manage pediatric/young adult cardio-oncology patients. The survey distribution was a collaborative effort between Cardio-oncology Section and membership of the Adult Congenital and Pediatric Cardiology Section (ACPC) of the ACC. Results: Sixty-five individuals, all self-identified as physicians, responded to the survey. Most respondents (n = 58, 89%) indicated childhood cancer patients are regularly screened prior to and during cancer therapy at their centers, predominantly by electrocardiogram (75%), standard echocardiogram (58%) and advanced echocardiogram (50%) (i.e. strain, stress echo). Evaluation by a cardiologist prior to/during therapy was reported by only 8(12%) respondents, as compared to post-therapy which was reported by 28 (43%, p < 0.01). The most common indications for referral to cardiology at pediatric centers were abnormal test results (n = 31,48%) and history of chemotherapy exposure (n = 27,42%). Of note, during post-treatment counseling, common cardiovascular riskfactors like blood pressure (31,48%), lipid control (22,34%), obesity & smoking (30,46%) and diet/exercise/weight loss (30,46%) were addressed by fewer respondents than was LV function (72%). Conclusions: The survey data demonstrates that pediatric cancer patients are being screened by EKG and/or imaging prior to/during therapy at most centers. Our data, however, highlight the potential for greater involvement of a cardiovascular specialist for pre-treatment evaluation process, and for more systematic cardiac risk factor counseling in posttreatment cancer survivors.

Cardiovascular disease and asymptomatic childhood cancer survivors: Current clinical practice

“…Practitioners surveyed in our study reported a lower threshold for initiating ACEi/ARB therapy compared to beta‐blocker or mineralocorticoid therapy. This has also been demonstrated by the ACC Pediatric Cardio‐Oncology Work Group 20 . While expert consensus supports the use of medical therapy in all asymptomatic patients with cardiomyopathy, efficacy data specific to CCS is lacking and in general, management strategies are primarily extrapolated from other populations 3,24‐28 .…”

“…This finding is supported by recent work from the American College of Cardiology (ACC) Pediatric Cardio‐Oncology Work Group. This group also demonstrated that patients were more likely to be evaluated by a cardiologist after completion of cancer therapy than prior to or during therapy 20 . It is unclear why adult cardiologists reported more referrals for CCS at increased risk for cardiovascular disease compared to survivorship practitioners or pediatric cardiologists.…”

“…Most pediatric cardiologists reported advanced heart failure/transplant as their primary field in contrast to adult cardiologists for whom almost half identified cardio‐oncology. This difference likely reflects disparities in educational opportunities as there is an absence of dedicated pediatric cardio‐oncology training programs in the United States 20,22 . It is likely that this is an area of potential need.…”

“…Additionally, the threshold of mild left ventricular systolic dysfunction for the initiation of medical therapy is an area of common clinical management strategy. Moving forward, these areas of common ground can be used to establish a multi‐institutional, standardized referral and clinical management approach for CCS, an endeavor supported by almost all survey respondents and by experts in this field 20,40 …”

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 ].…”