Cardiovascular testing rates 'poor' among adult survivors of childhood cancer
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Key takeaways:
- Many adult survivors of childhood cancer are not regularly screened for cardiovascular disease.
- Primary physicians do not always have survivors’ cancer history documented.
Adult survivors of childhood cancer with a high risk of cardiovascular disease may not be receiving proper cardiac testing, according to study findings published in JAMA Network Open.
Nearly one-third of the individuals studied did not have their cancer diagnosis documented with their primary care physicians (PCPs). Survivors with documentation that included their increased risk of cardiovascular disease or a long-term surveillance plan had significantly higher rates of testing.
“We found it disconcerting, though not necessarily unsurprising, that this group of high-risk patients had poor rates of adherence to guideline-concordant survivorship care,” Tim Ohlsen, MD, MS, pediatric oncologist at Seattle Children’s Hospital, told Healio. “However, given that up-to-date cardiac screening was associated with potentially modifiable factors, there is hope that interventions to increase patients’ and PCPs’ knowledge and/or provide communication reminders through medical record documentation may improve screening and survivorship outcomes for our patients along the trajectory of their lives.”
Background
More than 85% of the roughly 16,000 children who receive a cancer diagnosis in the U.S. annually survive at least 5 years. There are approximately 500,000 adult survivors living in the country, according to background information provided by the study investigators.
However, survivors are up to five times more likely to develop cardiovascular disease — the leading noncancer cause of early death in these individuals — because of the cancer-related treatments they received.
Modifiable risk factors for cardiovascular disease — including hypertension, dyslipidemia and diabetes — are more prevalent and more deadly among childhood cancer survivors than in the general population.
Guidelines for survivors suggest they should screen regularly for common risk factors of cardiovascular disease, but there is a research gap regarding real-world adherence to this guidance.
“The first step in intervening on cardiac late effects is detecting them,” Ohlsen said. “Given that most adults who are childhood cancer survivors receive much of their survivorship care by community-based PCPs, we were interested to see how patients at high risk for cardiac complications might interface with the health care system with regard to their survivorship health care utilization, particularly cardiac screening.”
Methods
Researchers conducted a multicenter cross-sectional study using participants in the Childhood Cancer Survivor Study (CCSS), an ongoing study of 5-year survivors of leukemia, lymphoma, renal tumors, sarcomas and central nervous system malignant neoplasms who were diagnosed before 21 years old from 1970-1999.
This cohort consisted of participants who had at least a 10% risk of ischemic heart disease or heart failure by the time they turned 50 years old based on criteria established in the randomized Communicating Health Information and Improving Coordination With Primary Care (CHIIP) study.
Participants required a home visit by an examiner between September 2017 and April 2021.
The frequency of PCP and specialist visits, cardiovascular risk factors, risk factor screening
and cardiac testing served as the study’s primary outcome measurements. Researchers used multivariable logistic regression analysis to determine characteristics associated with up-to-date cardiac testing at study enrollment.
Results and what’s next
Of the 293 eligible participants, 81.2% had a documented visit to a PCP in the 2 years prior to the study.
Based on PCPs medical records of participants, 82.3% had blood pressure testing, 61.1% had lipid testing, 65.9% underwent diabetes testing, 29% had cardiac testing and 21.5% had an echocardiogram.
According to participants’ self-reported records, 95.2% had blood pressure testing, 80.2% underwent lipid testing, 70.7% had diabetes testing and 38.9% had an echocardiogram.
Notably, 67.6% of study participants had their childhood cancer documented in their PCP records. Participants had 100% documentation in the CCSS records (P < .001).
Study patients had significantly lower rates of cancer treatment exposures reported in PCP records than in CCSS records, including records of radiation therapy (35.2% vs. 69.3%; P < .001) and anthracycline therapy (9.2% vs. 75.8%; P < .001).
Survivors with documentation stating their increased risk of cardiovascular disease (OR = 11.94; 95% CI, 3.37-42.31), existing risk factors (OR = 2.09; 95% CI, 1.32-3.31) or the need for late-effects surveillance (OR = 3.92; 95% CI, 1.69-9.11) had completed or planned cardiac testing at higher rates.
“We did find it exciting that documentation of risk and/or a late-effects surveillance plan were associated with greater odds of having up-to-date cardiac screening,” Ohlsen said. “Unfortunately, this study cannot tell us whether the act of documentation itself increased cardiac screening, or whether it was more reflective of a general awareness of risks for late effects.”
Ohlsen’s team is currently conducting a CHIIP trial to determine whether a “personalized survivorship care plan (SCP)” can break down communication barriers and improve knowledge about cancer survivor needs.
“Ultimately, I believe optimized survivorship care with PCPs may include documents like SCPs, as well as other initiatives to promote general awareness of cancer survivorship, increased access to survivorship services, and reduced financial and social barriers to follow-up for patients,” he told Healio. “If we can move the needle for cardiovascular late effects, we can hopefully do the same for all sorts of other long-term effects.”
Perspective
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Shahnawaz Amdani, MD, FACC, FAAP
There has been a significant improvement in survival for childhood cancers due to medical innovations and advancements over the last 5 decades. Their 5-year survival rates have increased from 58% in the mid-1970s to 85% currently, leading to a half- million such survivors living in the U.S. alone.
As these children are now living longer, it is becoming clear that they are at higher risk for additional multisystem comorbidities. Cardiovascular diseases are the leading noncancer-related reasons for mortality among childhood cancer survivors.
There is a significant gap in care that these childhood cancer survivors face, which was the subject of the current study. Ohlsen and colleagues found that only two-thirds of cancer survivors had a cancer history documented by their primary care provider, one-third had documentation about need for surveillance of late cancer treatment-related effects, and only one-fifth had surveillance echocardiograms completed or planned in the prior 2 years. These statistics are alarming.
To me, this reflects a missed opportunity to provide comprehensive care for these complex group of patients. As a health care system, we must build collaborative multidisciplinary clinics where these children and adults are cared for. Such clinics would include a primary care provider (pediatrician, internal medicine, or family medicine specialist), oncologist and cardio-oncologist. Caring for them collaboratively will lead to a significant rise in utilization of appropriate and timely cardiac surveillance testing that is required based on assessment of their individual cardiovascular risk. This will allow for initiation of timely preventive measures to reduce cardiovascular diseases and, ultimately, lead to further improvements in survival.
References:
American Cancer Society. Key statistics for childhood cancers. Available at: https://www.cancer.org/cancer/types/cancer-in-children/key-statistics.html. Accessed March 13, 2024.
Ohlsen TJD, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.47449.
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