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TAVR may be beneficial in cancer
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Patients with cancer treated with transcatheter aortic valve replacement for severe aortic stenosis appear to fare as well as patients without cancer in the short term but face a higher mortality rate at 1 year after treatment, according to a study.
Even so, Uri Landes, MD, from the cardiology department of Rabin Medical Center in Israel, said the findings, which were recently published in JACC: Cardiovascular Interventions, should not rule out TAVR in all patients with cancer.
“On the one hand, 85% of the patients survived 1 year after the TAVR. On the other hand, roughly half of the deaths were cancer-related. One may argue that 50% cancer mortality is a lot and should discourage us from TAVR in these patients. I believe that we should rather look at the glass half full — half of 15% means that merely 7.5% of the patients died from cancer and 92.5% didn’t,” he wrote in an email to Cardiology Today’s Intervention.
Increased mortality after TAVR
In the past, TAVR trials have excluded patients with limited life expectancy due to noncardiac conditions, such as cancer. With advances in medicine, though, the appropriate patient population for TAVR may be expanding, Landes noted.
“As cancer therapy improves, some patients with active cancer, including advanced metastatic diseases, have a decent prognosis (oncologically speaking) and may actually be more threatened by their severe aortic stenosis if left untreated. We had the opportunity to treat several such patients in our center, although there were no data to support such action. Also, we encountered a few asymptomatic patients with aortic stenosis in whom TAVR was indicated before cancer-related surgery or cardiotoxic anticancer therapy, and may have helped them to get through their anticancer therapy. Eventually, we were keen to collect data on such patients so to understand better their prognosis,” he said.
Landes and colleagues analyzed information from the TOP-AS registry, which collects data on patients undergoing TAVR while having all types of active malignancy with the exclusion of nonmelanoma skin cancer. They included 222 patients with cancer from 18 TAVR centers compared with 2,522 patients without cancer from five participating centers.
The researchers found no significant differences in in-hospital and 30-day mortality, cerebrovascular events, bleeding events, vascular complications, the need for a pacemaker or acute kidney injury between patients with and those without cancer.
However, among patients with cancer vs. those without cancer, mortality was higher (14.9% vs. 9%; P < .001) and survival was lower at 1 year (HR = 2.37; 95% CI, 1.74-3.23). When compared with patients without cancer, risk for mortality was higher in patients with stage 3 to 4 cancer at the time of TAVR (HR = 3.21; 95% CI, 2.35-4.35) but not in patients with stage 1 to 2 cancer (HR = 1.31; 95% CI, 0.96-1.78).
Among patients with cancer who died, three-quarters of deaths were not due to CV causes and one-half were attributable to cancer. Among those who survived at 1 year after TAVR, 29% had cancer progression, 9% had regression, 21% were in remission and 14% were considered cured from their oncological disease.
Additionally, one-half of patients with cancer were NYHA functional class I at both 1 month and 1 year after TAVR.
The mean age of the patients with cancer was 78.8 years. They had a Society of Thoracic Surgeons score of 4.9% and 62% were men. The most common cancers were gastrointestinal (22%), prostate (16%), breast (15%), hematologic (15%) and lung (11%). One-half had stage 3 to 4 cancer, 31% had metastasis, 29% were receiving antineoplastic therapy and 26% had an indication for downstream cancer-related surgery.
Importance of the heart team
In an accompanying editorial, Niklas Schofer, MD, from the department of general and interventional cardiology at the University Heart Center Hamburg in Germany, noted that this study, along with others, demonstrates that the number of patients with cancer undergoing TAVR is increasing, highlighting the importance of a multidisciplinary approach to treating these patients.
“The present study provides evidence that it is crucial to involve specialized oncologists in the heart team decision before TAVR to accurately define the stage of malignancy and the estimated life expectancy,” he wrote, adding that severe aortic stenosis symptoms often overlap with those of neoplastic disease.
Only patients with truly symptomatic severe aortic stenosis, Schofer noted, should be considered for TAVR.
He also highlighted the lower STS score, despite worse outcomes, observed in patients with cancer vs. those without cancer in the study.
“This indicates that the attributable risk of cancer is not represented in currently available surgical risk scores,” Schofer wrote. “Applying additional risk scores to cancer patients, for example, frailty assessment by using the ‘Katz index’ or the ‘Kanofski performance status,’ might improve risk assessment in this patient population.”
The study was also not without limitations, according to Schofer. The inclusion of a wide variety of cancer types and grades of malignancy and the lack of data on quality of life after TAVR, comparison between TAVR and optimal medical therapy and a cost-effectiveness analysis leave more questions to be answered.
Nevertheless, TAVR may be appropriate for patients with early-stage cancer, Schofer wrote.
Landes also listed areas that the researchers would like to see studied further.
“Our study may indicate that although TAVR in patients with cancer is associated with worse outcomes compared with cancer-free patients, it’s still associated with a relatively good prognosis,” he said. “We saw that cancer stage is extremely important. I think that further study should focus on evaluating TAVR vs. palliative care for cancer patients with severe aortic stenosis, mainly and specifically in patients with stage 3 to 4 cancer in whom the cost-effective balance is more vague.”
Overall, the study underscores the importance of the heart team in decision-making, according to Landes.
“Treating severe aortic stenosis with TAVR in oncology patients appears effective and safe at the short-term, but carries a worse 1-year prognosis. Among this cohort, mortality is largely due to cancer, yet 85% of patients are alive at 1 year, and importantly, one-third of them are either in remission or cured of their oncologic disease at that time. Basically, that means that the heart team should make individual case decisions. It is essential that an oncologist will be integrated into the heart team when discussing the optimal treatment strategy in such cases,” he told Cardiology Today’s Intervention. – by Melissa Foster
For more information:
Uri Landes, MD, can be reached at uri.landes@gmail.com.
Disclosures: Landes reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Schofer reports he has received travel compensation from Boston Scientific, Edwards Lifesciences and St. Jude Medical, and he has received speaking honoraria from Boston Scientific.
Perspective
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Chandan Devireddy, MD, FSCAI, FACC
The TOP-AS registry is the first study to evaluate a multicenter cohort of patients with known malignancy in the contemporary TAVR era. Where oncologic patients were often previously restricted from access to TAVR, these patients, as shown in the study, represent a growing proportion of those presenting to valve clinics for evaluation for valve replacement. This registry demonstrates that TAVR is a safe procedure in these patients and that many gain benefit in both survival and quality of life. However, the most significant benefits may be primarily limited to those with earlier stages of malignancy.
I do feel that, anecdotally, our valve center has seen an increase in referrals of patients suffering from malignancies. We are limited in our predictive ability but have tried to engage with both the patient and their oncologist to employ shared decision making regarding the risks and potential benefits of TAVR. The TOP-AS registry provides further evidence to help shape these conversations. It supports the observation that we are seeing more of these patients and that, when carefully chosen, allows them to quickly pursue advanced options such as chemotherapy or surgery, which would be difficult after surgical AVR. However, the marked reduction in survival in patients with stage III to IV disease is a reminder that patient selection and coordination with oncology is of primary importance in identifying those who will benefit.
The authors are to be commended in gathering an international, multicenter "all-comers" registry of a poorly understood patient population that is being seen more often in valve clinics. As a registry, however, of patients undergoing a TAVR procedure, there is obvious bias without knowing the characteristics of those patients who were never offered the procedure to begin with. Further studies may optimize decision making by valve disease specialists by exploring outcomes from the time of first referral. Also, it is difficult to know whether certain malignancies behave differently than others post-TAVR given the relatively small sample size of the study.
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