Fewer cardiac screenings may be appropriate for pediatric cancer survivors

Issue: January 25, 2015

Less frequent cardiac screening to detect asymptomatic left ventricular dysfunction and reduce the risk for congestive heart failure among pediatric cancer survivors who were exposed to anthracycline chemotherapy may be as effective as more frequent screening schedules but more cost-effective, according to results of two modeling studies published in Annals of Internal Medicine.

“It is important to monitor survivors so we can reduce the late effects of treatment whenever possible, but we may be asking them to be tested too often, which burdens both individuals and the health care system,” study researcher Lisa Diller, MD, chief medical officer of Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, said in a press release. “We think it is worthwhile to review the current [congestive heart failure] screening guidelines.”

Lisa Diller

Using data from the Childhood Cancer Survivor Study, F. Lennie Wong, PhD, and colleagues simulated life histories from 10 million childhood cancer survivors from 5 years after their initial diagnosis until death.

Screening according to Children’s Oncology Group guidelines — which recommend echocardiography screening every 1 to 5 years according to lifetime anthracycline doses, age at diagnosis, chest irradiation history and other risk factors — was associated with an incremental cost-effectiveness ratio of $61,500 per quality-adjusted life-year gained and an 18% reduction in the incidence of heart failure 30 years after diagnosis compared with no screening.

When researchers estimated outcomes for low-risk subgroups with screening every 10 years and high-risk subgroups with screening every 5 years, they found the cost-effectiveness ratio was improved to $33,200 with a 14.3% reduction in heart failure risk at 30 years.

In the other study, Jennifer Yeh, PhD, of the Center for Health Decision Science at Harvard School of Public Health, Anju Nohria, MD, of Brigham and Women’s Hospital, and Diller developed a simulation model of 5-year childhood cancer survivors aged 15 years. They classified low-risk patients as those who received less than 250 mg/m² anthracycline and high-risk patients as those who received at least 250 mg/m² anthracycline.

Jennifer Yeh

Without screening, pediatric cancer survivors were at an expected 18.8% lifetime risk for systolic congestive heart failure (CHF), a 22.6% risk for asymptomatic left ventricular dysfunction and an 11.1% risk for death from CHF.

Researchers then calculated CHF risk reductions and incremental cost-effectiveness ratios per quality-adjusted life-year gained with various 2-D echocardiography screening schedules — all which commenced 5 years after cancer diagnosis — compared with no screening.

Screening every 10 years was associated with a 2.3% CHF risk reduction and $111,600 per life-year gained, whereas yearly screening was associated with an 8.7% risk reduction and $278,600 per life-year gained.

They determined that screening with cardiac MRI instead of echocardiography reduced the risk for CHF and improved cost-effectiveness when repeated every 10 years among low-risk subgroups (risk reduction, 4.6%; cost per life-year gained, $78,000) and every 5 years among high-risk subgroups (risk reduction, 6.1%; cost per life-year gained, $89,800).

“Our findings suggest that there is a long-term benefit in screening survivors at elevated risk for CHF,” Yeh said in a press release. “Yet, less frequent screening than currently recommended may be reasonable when other factors are considered.”

In an accompanying editorial, Richard M. Steingart, MD; Jennifer E. Liu, MD; and Kevin C. Oeffinger, MD, of the Memorial Sloan Kettering Cancer Center, wrote that although the two studies may differ on their risk subgroup classification and screening recommendations, both suggest intervals between screening may be extended with similar efficacy and lowered costs.

“Yeh and Wong and their colleagues point out the scope of the problem and remind us that screening for cardiomyopathy can be done cost-effectively and is highly likely to improve the quality and quantity of the patient’s life,” they wrote. “The clinician and patient should be assured that screening for asymptomatic left ventricular dysfunction is a valuable undertaking and that state-of-the-art cost-effectiveness analyses allow for variation in their choices based on the details of the clinical presentation, patient preference and local imaging expertise.”

For more information:

Steingart RM. Ann Intern Med. 2014;160:731-732.
Wong FL. Ann Intern Med. 2014;160:672-683.
Yeh JM. Ann Intern Med. 2014;160:661-671.

Disclosure: Liu, Oeffinger and Steingart report no relevant financial disclosures. See the studies for the remaining researchers’ relevant financial disclosures.