ASCO Clinical Practice Guideline on Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers


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Jean-Bernard Durand, MD

Jean-Bernard Durand, MD

Saro H. Armenian, DO, MPH

Saro H. Armenian, DO, MPH

As reported in the Journal of Clinical Oncology by Saro H. Armenian, DO, MPH, of City of Hope, and colleagues, ASCO has released a clinical practice guideline on prevention and monitoring of cardiac dysfunction in survivors of adult cancers.1 Recommendations were developed by an expert panel using a systematic review of meta-analyses, randomized clinical trials, observational studies, and clinical experience covering the period 1996 to 2016.

A total of 104 studies met eligibility criteria and provide the evidentiary basis for the recommendations. The expert panel was co-chaired by Dr. Armenian and Jean-Bernard Durand, MD, of MD Anderson Cancer Center.

The recommendations are reproduced/summarized below, according to guideline clinical questions. The type of recommendation, evidence quality, and strength of recommendation are shown in brackets.

Recommendations

1. Which patients with cancer are at increased risk for developing cardiac dysfunction?

1.1. It is recommended that patients with cancer who meet any of the following criteria should be considered at increased risk for developing cardiac dysfunction:

Treatment that includes any of the following:

  • High-dose anthracycline (eg, doxorubicin at ≥ 250 mg/m2, epirubicin at ≥ 600 mg/m2)
  • High-dose radiotherapy (≥ 30 Gy) where the heart is in the treatment field
  • Lower-dose anthracycline (eg, doxorubicin at < 250 mg/m2, epirubicin at < 600 mg/m2) in combination with lower-dose radiotherapy (< 30 Gy) where the heart is in the treatment field

Treatment with lower-dose anthracycline or trastuzumab [Herceptin] alone and the presence of any of the following risk factors:

  • Multiple cardiovascular risk factors (≥ two risk factors), including smoking, hypertension, diabetes, dyslipidemia, and obesity, during or after completion of therapy
  • Older age (≥ 60 years) at cancer treatment
  • Compromised cardiac function (eg, borderline low left-ventricular ejection fraction [50% to 55%], history of myocardial infarction, ≥ moderate valvular heart disease) at any time before or during treatment

Treatment with lower-dose anthracycline followed by trastuzumab (sequential therapy).

[Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

1.2. No recommendation can be made on the risk of cardiac dysfunction in patients with cancer with any of the following treatment exposures:

Lower-dose anthracycline or trastuzumab alone and no additional risk factors (as defined in Recommendation 1.1)

Lower-dose radiotherapy (< 30 Gy) where the heart is in the treatment field and no additional cardiotoxic therapeutic exposures or risk factors (as defined in Recommendation 1.1)

Kinase inhibitors. [Evidence based; evidence quality: low]

Clinicians should perform a comprehensive assessment in patients with cancer that includes a history and physical examination, screening for cardiovascular disease risk factors, and an echocardiogram before initiation of potentially cardiotoxic therapies.
— Saro H. Armenian, DO, MPH, and colleagues

2. Which preventative strategies minimize risk before initiation of therapy?

2.1. Avoid or minimize the use of potentially cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes. [Consensus based; benefits outweigh harms; strength of recommendation: strong]

2.2. Clinicians should perform a comprehensive assessment in patients with cancer that includes a history and physical examination, screening for cardiovascular disease risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking), and an echocardiogram before initiation of potentially cardiotoxic therapies. [Evidence and consensus based; benefits outweigh harms; evidence quality: high; strength of recommendation: strong]

3. Which preventive strategies are effective in minimizing risk during the administration of potentially cardiotoxic cancer therapy?

3.1. Clinicians should screen for and actively manage modifiable cardiovascular risk factors in all patients receiving potentially cardiotoxic treatments. [Informal consensus and evidence based; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate]

3.2. Clinicians may incorporate a number of strategies, including the use of the cardioprotectant dexrazoxane, continuous infusion, or liposomal formulation of doxorubicin, for prevention of cardiotoxicity in patients planning to receive high-dose anthracyclines. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

3.3. For patients who require mediastinal radiotherapy that might impact cardiac function, clinicians should select lower radiation doses when clinically appropriate and use more precise or tailored radiation fields with exclusion of as much of the heart as possible. These goals can be accomplished through the use of advanced techniques including the following: deep-inspiration breath holding for patients with mediastinal tumors or breast cancer in which the heart might be exposed; intensity-modulated radiotherapy that varies the radiation energy while treatment is delivered to precisely contour the desired radiation distribution and avoid normal tissues. [Evidence based and informal consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: strong]

4. What are the preferred surveillance and monitoring approaches during treatment in patients at risk for cardiac ­dysfunction?

4.1. Clinicians should complete a careful history and physical examination in patients who are receiving potentially cardiotoxic treatments. [Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong]

4.2. In individuals with clinical signs or symptoms concerning for cardiac dysfunction during routine clinical assessment, the following strategy is ­recommended:

Echocardiogram for diagnostic workup [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: strong]

Cardiac magnetic resonance imaging (MRI) or multigated acquisition scan if echocardiogram is not available or technically feasible (eg, poor image quality), with preference given to cardiac MRI. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Serum cardiac biomarkers (troponins, natriuretic peptides) or echocardiography-derived strain imaging in conjunction with routine diagnostic imaging. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Referral to a cardiologist based on findings. [Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong]

4.3. Routine surveillance imaging may be offered during treatment in asymptomatic patients considered to be at increased risk (Recommendation 1.1) of developing cardiac dysfunction. In these individuals, echocardiography is the surveillance imaging modality of choice that should be offered. Frequency of surveillance should be determined by health-care providers based on clinical judgment and patient circumstances. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

4.4. No recommendations can be made regarding continuation or discontinuation of cancer therapy in individuals with evidence of cardiac dysfunction. This decision, made by the oncologist, should be informed by close collaboration with a cardiologist, fully evaluating the clinical circumstances and considering the risks and benefits of continuation of therapy responsible for the cardiac dysfunction. [Informal consensus; benefits outweigh harms; evidence quality: insufficient]

4.5. Clinicians may use routine echocardiographic surveillance in patients with metastatic breast cancer continuing to receiving trastuzumab indefinitely. The frequency of cardiac imaging for each patient should be determined by health-care providers based on clinical judgment and patient circumstances. [Evidence based and informal consensus; benefits outweigh harms; evidence quality: low; strength of recommendation: moderate]

5. What are the preferred surveillance and monitoring approaches after treatment in patients at risk for cardiac dysfunction?

5.1. Clinicians should complete a careful history and physical examination in survivors of cancer previously treated with potentially cardiotoxic therapies. [Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong]

5.1.1. In individuals with clinical signs or symptoms concerning for cardiac dysfunction, the following approaches should be offered as part of recommended care:

Echocardiogram for diagnostic workup. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: strong]

Cardiac MRI or multigated acquisition if echocardiogram is not available or technically feasible (eg, poor image quality), with preference given to cardiac MRI. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Serum cardiac biomarkers (troponins, natriuretic peptides). [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

Referral to a cardiologist based on findings. [Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong]

5.2. An echocardiogram may be performed between 6 and 12 months after completion of cancer-directed therapy in asymptomatic patients considered to be at increased risk (Recommendation 1.1) of cardiac dysfunction. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

5.2.1. Cardiac MRI or multigated acquisition may be offered for surveillance in asymptomatic individuals if an echocardiogram is not available or technically feasible (eg, poor image quality), with preference given to cardiac MRI. [Evidence based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate]

5.3. Patients identified to have asymptomatic cardiac dysfunction during routine surveillance should be referred to a cardiologist or a health-care provider with cardio-oncology expertise for further assessment and management. [Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong]

5.4. No recommendations can be made regarding the frequency and duration of surveillance in patients at increased risk (Recommendation 1.1) who are asymptomatic and have no evidence of cardiac dysfunction on their 6- to 12-month posttreatment echocardiogram. [Informal consensus; relative balance of benefits and harms; evidence quality: insufficient]

5.5. Clinicians should regularly evaluate and manage cardiovascular risk factors in patients previously treated with cardiotoxic cancer therapies. A heart-healthy lifestyle, including the role of diet and exercise, should be discussed as part of long-term follow-up care. [Evidence based and consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate] ■

Disclosure: For full disclosures of the study authors, visit www.jcoascopubs.org.

Reference

1. Armenian SH, Lacchetti C, Barac A, et al: Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 35:893-911, 2017.


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The commitment of all involved to produce a balanced and sensible document, which might actually help clinicians decide how to manage potential cardiac dysfunction in adult cancer survivors, should be enthusiastically celebrated.
— Daniel J. Lenihan, MD

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