Author + information
- Dorothy M. Gujral, PhD,
- Guy Lloyd, MD and
- Sanjeev Bhattacharyya, MD∗ ()
- ↵∗Echocardiography Laboratory, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, United Kingdom
Cardiotoxicity is a complication of a range of modern cancer therapies, including chemotherapy, targeted agents, and radiotherapy (1). There is increasing support for developing dedicated cardio-oncology services given the complexities and need for rapid assessment, risk stratification, and treatment of patients who require chemotherapeutic treatment, as well as longer-term follow-up (2). We sought to investigate the current provision of cardio-oncology services to determine the methods used to detect and monitor patients at risk for cardiovascular complications related to cancer therapy.
An electronic survey was distributed to comprehensive cancer centers across the United States and Europe (National Comprehensive Cancer Network and Organisation of European Cancer Institute) and all cancer centers providing both chemotherapy and radiotherapy within the United Kingdom. We collected data on the provision and organization of cardio-oncology services, as well as on the frequency and modality of cardiovascular screening and the use of cardiovascular biomarkers. The survey was sent to the lead staff clinician at each cancer center. Reminders were sent to nonresponders or partial responders at weekly intervals. If no response was received, the survey was sent to another staff oncologist within the cancer center. The study period ran from May to July 2015.
A total of 113 of 156 oncology centers (72%) responded. Dedicated cardio-oncology clinics were conducted at 33 of the 66 international comprehensive cancer centers (52%), and 6 of the 47 U.K. cancer centers responded (13%). At the 74 cancer centers with no formal cardio-oncology clinics, patients who required cardiovascular input were referred to designated cardiologists at hospitals affiliated with the cancer centers at 24 centers (32%) or the patients’ local hospitals at 50 centers (68%).
Table 1 shows the method and frequency of monitoring performed for the detection of cardiotoxicity between centers with and without cardio-oncology clinics. During trastuzumab therapy, there was no difference in frequency or modality used to identify cardiotoxicity. However, a significantly greater proportion of centers with cardio-oncology clinics performed 6-month post-treatment assessment of left ventricular function compared with those centers without cardio-oncology clinics (54% vs. 9%, p < 0.001). In addition, cancer centers with cardio-oncology clinics were more likely to use biomarkers than those without (brain natriuretic peptide at 21% vs. 5%, p = 0.02; troponin at 18% vs. 4%, p = 0.03).
In patients requiring anthracycline therapy, a significantly greater proportion of centers with cardio-oncology clinics performed baseline echocardiography compared with those without cardio-oncology clinics (74% vs. 53%, p = 0.02). In addition, a significantly greater proportion of centers with cardio-oncology services performed post-anthracycline assessment of left ventricular function compared with those without cardio-oncology clinics (33% vs. 15%, p = 0.04).
Overall, 13 of 113 cancer centers (12%) monitored cardiac function in patients who received radiotherapy to the mediastinum or left breast. A significantly greater proportion of cancer centers with cardio-oncology clinics performed cardiac follow-up after radiotherapy compared with centers without cardio-oncology clinics (23% vs. 5%, p = 0.01).
This study shows limited provision of cardio-oncology clinics (approximately 52%) at international comprehensive cancer centers. However, these may not be representative of the standard of care at many general hospitals. Therefore, all U.K. cancer centers were selected as a comparator. Only 13% of these centers had cardio-oncology clinics.
An integral question is whether the provision of a cardio-oncology clinic improves the detection of cardiotoxicity. We identified important differences between centers with and those without cardio-oncology clinics. Cancer centers with cardio-oncology clinics performed more intensive monitoring for cardiotoxicity in patients undergoing anthracycline chemotherapy, adjuvant trastuzumab treatment, as well as longer-term monitoring for complications related to radiotherapy. Our study was limited, as we studied only the most common forms of cardiotoxicity (related to anthracyclines, trastuzumab, and radiotherapy).
The wide variation in practice among cancer centers may reflect a lack of consensus on the optimal strategy to detect cardiac toxicity. Although European guidelines exist, there are no U.S. guidelines (3). Furthermore, there is no consensus on the organization of cardio-oncology services. We propose collaboration among international cardiovascular and oncology societies to define the optimal organization of cardio-oncology services, protocols for the detection and management of cardiotoxicity, and audit standards to measure the effect of services on patient outcomes.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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