Uptake of echocardiography amongst different risk groups for patients treated with cardiotoxic chemotherapy
Authors: Chandrakumar D , Malaty M , Li C , Jethwani U , Gan GCH , Tan TC 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Cardiovascular complications of cancer therapy are increasingly becoming a significant medical issue. Hence, the role of cardiovascular imaging in the assessment of baseline cardiovascular risk is becoming increasingly important. Current guidelines recommend a baseline transthoracic echocardiogram (TTE) prior to commencement of cardiotoxic chemotherapy (CC) but the uptake is presently inconsistent.

Purpose
Our study aimed to determine the uptake of a baseline TTE in a cohort of patients with solid organ malignancies (SOM) prior to commencing their treatment and to examine the patterns of uptake based on the risk of development of cardiotoxicity.

Methods
Patients with a SOM admitted to our institution between 2014-18 were examined. Demographic data, clinical comorbidities, cancer type, and chemotherapeutic regimens used were obtained from the patient’s electronic medical record. Included patients were divided into those receiving one of the 8 CC classes identified in the Cardio-Oncology Study Group and International Cardio-Oncology Society (COSG/ICOS) 2020 position statement1, and those who did not (control group). Those receiving CC were further stratified into risk groups according to the proformas proposed by the COSG/ICOS, while patients receiving immunotherapy for whom a proforma was not available, were considered a separate group. The uptake patterns of TTE in each group determined.

Results
Of 800 patients reviewed, 712 patients were included, and categorised into groups as shown in figure 1. Patients treated with CC had low uptake of a baseline TTE, and there was no difference compared to controls (14.4% vs 13.9%, p = 0.9). They were however more likely to have received a TTE during the course of treatment (32.3% vs 23.2%, p = 0.009). Figure 2 shows the rates of baseline TTE stratified by risk group. Compared to patients not on CC, only very high risk patients had a higher rate of baseline TTE (p &lt; 0.001), while low risk patients had lower rates (p = 0.005). Compared to those not on CC, there was no difference in the rate of baseline TTE amongst immunotherapy patients, medium risk and high risk patients.

Conclusion
The uptake of baseline TTE in accordance with guidelines amongst patients receiving CC was very low. Based on the risk stratification proformas proposed by the COSG/ICOS, only very high risk patients were having a baseline TTE more frequently than those not treated with CC. The risk of future cardiotoxicity amongst low, medium and high risk patients, and those receiving immunotherapy, appears to be underappreciated, as these patients were not screened by TTE prior to commencing therapy. Increasing awareness of the agents that cause cardiotoxicity, and the establishment of formal protocols for these patients, may increase compliance with recommendations for TTE prior to commencing CC. Abstract Figure. Distribution of patients by risk group Abstract Figure. Percentage of patients with baseline TTE