Primary care utilization and cardiovascular screening in adult-aged survivors of childhood cancer: A report from the childhood cancer survivor study (CCSS).
Authors: Ohlsen Timothy James Daeeun , Chen Yan , Baldwin Laura-Mae , Hudson Melissa M. , Nathan Paul C. , Snyder Claire Frances , Syrjala Karen L , Tonorezos Emily S. , Yasui Yutaka , Armstrong Gregory T. , Oeffinger Kevin C. , Chow Eric Jessen 
Published: June 2023

e22020

Background: Among the half million survivors of childhood cancer in the US, cardiovascular disease (CVD) is the leading non-cancer cause of premature death. Adult survivors of childhood cancer are largely managed by community-based primary care providers (PCPs), and healthcare utilization patterns related to CVD screening and survivorship care are not well-described. Methods: Within the CCSS cohort, we conducted a randomized intervention trial (NCT03104543) focused on improving CVD risk factor control among survivors at increased risk for CVD due to prior chest radiotherapy and/or anthracycline chemotherapy. Using medical records from participants’ PCPs over the 2 years preceding trial enrollment, we ascertained the numbers of PCP and specialist visits, CVD conditions (i.e., hypertension, dyslipidemia, diabetes) and screening (i.e., blood pressure, lipid, diabetes testing, and cardiac testing [ECG, echocardiogram, or other imaging completed or planned]). We also abstracted acknowledgement of participants’ cancer history, cardiotoxic treatment exposures, or a survivorship care plan (SCP). Multivariable logistic regression assessed characteristics associated with having cardiac testing, retaining covariates associated with p < 0.10 in univariate testing. Results: Of 347 enrolled participants, 293 (84%) had evaluable data (median age 40y, range 22–65; 49% female; 87% non-Hispanic White; mean 31y since childhood cancer). In the prior 2y, 81% of participants had a documented PCP office visit (median 3 visits [IQR 2–5]), 22% had a subspecialty visit (4% saw cardiology), and 16% had no visits. The prevalence of blood pressure, lipid, and diabetes screening was 82%, 57%, and 63%, respectively; 29% had cardiac testing done or planned, including 22% with echocardiography. Only 68% of participants had records referencing a history of cancer. PCP documentation of prior cardiotoxic exposures was low compared with known exposures: radiotherapy (35% vs 69%; p < 0.001), anthracycline chemotherapy (9% vs 76%; p = 0.017); only 12% had any documentation noting an increased risk for CVD. Few participants’ records referenced a need for cancer-related late effects surveillance (38%), and even fewer referenced an SCP (5%). In multivariable analysis, independent predictors of cardiac testing included documentation of increased CVD risk (Odds Ratio [OR] 11.61, 95% CI 3.31–40.67), presence of a late effects surveillance plan (OR 3.71, 95% CI 1.62–8.48), and existing CVD conditions (modeled as 0, 1, or 2+ conditions; OR 2.21, 95% CI 1.41–3.47, for each additional level). Conclusions: Adult survivors of childhood cancer at increased risk of CVD had low rates of cardiac testing and documentation of risk in PCP medical records. Increasing participant and PCP awareness of CVD risks and late effects surveillance recommendations may improve screening.