Improving Screening Practices in Childhood Cancer Survivors at Risk for Treatment-Related Heart Failure
Authors: Saro H. Armenian
Journal: Journal of Clinical Oncology (2014)

Advances in diagnostic precision, therapy, and supportive care for children with cancer have resulted in marked improvements in long-term survival; overall 5-year survival for most children with cancer exceeds 80%, contributing to a growing number of childhood cancer survivors in the United States. However, research on survivorship issues over the past three decades has demonstrated well-established associations between therapeutic exposures and subsequent adverse health-related complications such as second malignant neoplasms, premature cardiovascular disease, endocrinopathies, growth and musculoskeletal complications, and neurocognitive disorders. It is estimated that by age 50, up to half of all childhood cancer survivors will develop a severe or life-threatening health-related complication, with no plateau of risk over time. Many of these complications do not become clinically apparent until years after completion of therapy, a time when many survivors are no longer in active follow-up at their primary cancer treatment center. Recognizing the importance of developing a systematic plan for lifelong surveillance of health-related complications, the Children’s Oncology Group (COG) developed guidelines (Long Term Follow-up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers) that provide risk-based, exposure-related recommendations for early screening, regardless of clinical setting. Importantly, these guidelines are readily accessible and include informational patientdirected Health Links to enhance health promotion in this population. Nevertheless, despite the availability of these guidelines, many childhood cancer survivors do not receive risk-based follow-up care. For example, in the Childhood Cancer Survivor Study (CCSS), only 28% of childhood cancer survivors identified to be at high risk of developing heart failure (HF) reported having had a screening echocardiogram in the previous 2 years. This is especially sobering because cardiovascular complications such as HF have emerged as a leading cause of long-term morbidity and mortality in the growing population of childhood cancer survivors. The lack of appropriate risk-based follow-up care in this population is attributed to a number of inadequacies, including availability of established long-term follow-up programs at the primary treatment center, systems to facilitate transition from pediatric to adult-centered care, and knowledge among survivors about their treatment and subsequent risk for health-related complications. Furthermore, obstacles within the health care system contribute to this lack of risk-based follow-up care, such as lack of health insurance and access to preventive care. In the article accompanying this editorial, Hudson et al present their findings from a study to improve adherence to recommended echocardiographic screening in childhood cancer survivors at risk for HF. In this population of survivors, it is well recognized that there is a long latency ( 10 years) between cardiotoxic (anthracycline and/or chest radiation therapy) therapeutic exposures and onset of HF. Outcomes are generally poor once an individual develops clinical evidence of HF, with reported 5-year survival rates of less than 50%. The interim period between exposure and clinically evident HF is characterized by chronic left ventricular remodeling, which often manifests as asymptomatic cardiomyopathy (abnormal systolic and or diastolic function). Routine screening with echocardiography enables health care providers to detect early subclinical disease, setting the stage for interventions to delay or prevent the onset of HF. As such, it is especially important that strategies be developed to improve adherence to early screening, taking into consideration existing barriers such as access to established childhood cancer survivorship centers. For their study, Hudson et al leveraged the existing infrastructure of the CCSS to examine whether the delivery of tailored telephone counseling by advance practice nurses (APN) as an addition to standard of care (mailed personalized survivorship care plan), would increase the proportion of at risk survivors who completed cardiomyopathy screening. Recognizing that a substantial proportion of survivors are not regularly monitored in established survivorship clinics, the investigators relied on distance-delivered interventions (via mail and telephone) that included two brief telephone counseling sessions conducted by an APN. Survivors were eligible to participate if they were 25 years of age, had received cardiotoxic exposures during cancer treatment, were not actively participating in a long-term follow-up programthatprovidedrisk-basedscreening,andhadnotreceivedcardiomyopathy screening during the 5 years before study enrollment. At the 1-year postintervention time point, survivors in the APN group were more than twice as likely than those in the standard of care arm to undergo recommended cardiomyopathy screening, as verified by self-report and confirmed by review of patient medical records. Although the investigators did not find specific subgroups that derived more benefit from the intervention, their subanalyses regarding reasons for not obtaining a screening echocardiogram are especially important. Patients assigned to the APN arm were more likely to identify concerns about insurance coverage of testing as a reason for not undergoing screening. On the other hand, patients who received JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 35 DECEMBER 1