Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline

Saro H. Armenian, Christina Lacchetti, Ana Barac, Joseph Carver, Louis S. Constine, Neelima Denduluri, Susan Dent, Pamela S. Douglas, Jean-Bernard Durand, Michael Ewer, Carol Fabian, Melissa Hudson (+9 others)
2017 Journal of Clinical Oncology  
Cardiac dysfunction is a serious adverse effect of certain cancer-directed therapies that can interfere with the efficacy of treatment, decrease quality of life, or impact the actual survival of the patient with cancer. The purpose of this effort was to develop recommendations for prevention and monitoring of cardiac dysfunction in survivors of adult-onset cancers. Methods Recommendations were developed by an expert panel with multidisciplinary representation using a systematic review (1996 to
more » ... 016) of meta-analyses, randomized clinical trials, observational studies, and clinical experience. Study quality was assessed using established methods, per study design. The guideline recommendations were crafted in part using the Guidelines Into Decision Support methodology. Results A total of 104 studies met eligibility criteria and compose the evidentiary basis for the recommendations. The strength of the recommendations in these guidelines is based on the quality, amount, and consistency of the evidence and the balance between benefits and harms. Recommendations It is important for health care providers to initiate the discussion regarding the potential for cardiac dysfunction in individuals in whom the risk is sufficiently high before beginning therapy. Certain higher risk populations of survivors of cancer may benefit from prevention and screening strategies implemented during cancer-directed therapies. Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy. For certain higher risk survivors of cancer, routine surveillance with cardiac imaging may be warranted after completion of cancer-directed therapy, so that appropriate interventions can be initiated to halt or even reverse the progression of cardiac dysfunction. J Clin Oncol 35:893-911. Recommendation 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? Recommendation 3.1. Clinicians should screen for and actively manage modifiable cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, obesity) in all patients receiving potentially cardiotoxic treatments. (Informal consensus and evidence based; benefits outweigh harms; Evidence quality: insufficient; Strength of recommendation: moderate) Recommendation 3.2. Clinicians may incorporate a number of strategies, including use of the cardioprotectant dexrazoxane, continuous infusion, or liposomal formulation of doxorubicin, for prevention of cardiotoxicity in patients planning to receive high-dose anthracyclines (eg, doxorubicin $ 250 mg/m 2 , epirubicin $ 600 mg/m 2 ). (Evidence based; benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: moderate) Recommendation 3.3. For patients who require mediastinal RT 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 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 RT 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? Recommendation 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) Recommendation 4.2. In individuals with clinical signs or symptoms concerning for cardiac dysfunction during routine clinical assessment, the following strategy is recommended:
doi:10.1200/jco.2016.70.5400 pmid:27918725 fatcat:e2f6rj6r6jdd7hlrxi7h3dmivy