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Canadian Journal of Cardiology

Cardiac Outcomes in Survivors of Pediatric and Adult Cancers

  • Paul C. Nathan
    Correspondence
    Corresponding author: Dr Paul C. Nathan, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada. Tel.:+1-416-813-7743; fax: +1-416-813-5327.
    Affiliations
    Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada

    Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada

    Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Eitan Amir
    Affiliations
    Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

    Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Husam Abdel-Qadir
    Affiliations
    Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

    Division of Cardiology, Women's College Hospital, Toronto, Ontario, Canada
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Published:March 01, 2016DOI:https://doi.org/10.1016/j.cjca.2016.02.065

      Abstract

      More than 80% of children and 60% of adults with cancer will become long-term survivors, emphasizing the importance of late effects of cancer therapy. Cardiotoxicity due to chemotherapy and radiation is a frequent cause of serious morbidity and premature mortality in survivors. Anthracyclines, a core component of many treatment regimens, have been implicated as a principal cause of irreversible cardiomyopathy. Approximately 60% of anthracycline-treated children will develop echocardiographic evidence of cardiac dysfunction, and 10% of those treated with high-dose anthracyclines will develop congestive heart failure within the 20 years after therapy. Adults treated with trastuzumab are at risk of a cardiomyopathy that is usually reversible. As many as 12% of adults treated with trastuzumab and 20% of those who have also received an anthracycline will develop cardiotoxicity within 5 years. Risk factors for cardiomyopathy include patient (eg, age, sex, genetic predisposition) and treatment characteristics (eg, cumulative anthracycline dose). Radiotherapy to a field involving the heart increases the risk of cardiomyopathy, coronary artery disease, valvular dysfunction, arrhythmias, and pericardial disease. Surveillance guidelines are available to guide long-term cardiac follow-up of childhood cancer survivors, but not for survivors of adult cancers; however, periodic follow-up to detect cardiac dysfunction may be reasonable. Modifiable cardiac risk factors such as hypertension, smoking, and dyslipidemia interact with cancer therapies to increase the risk of cardiac disease, emphasizing the importance of risk-factor control. Coordination of care between oncologists and cardiologists would optimize care for those individuals at high risk of cardiotoxicity who would benefit from appropriate surveillance and treatment strategies.

      Résumé

      Plus de 80 % des enfants et 60 % des adultes atteints de cancer y survivront à long terme, ce qui met en évidence l’importance des effets retards du traitement anticancéreux. La cardiotoxicité causée par la chimiothérapie et la radiothérapie est une cause fréquente de morbidité grave et de mortalité précoce chez les survivants. Les anthracyclines, une composante importante de nombreux schémas thérapeutiques, ont été pointées du doigt comme principale cause de la cardiomyopathie irréversible. Environ 60 % des enfants traités par des anthracyclines présenteront des signes de dysfonction cardiaque à l’échographie et 10 % des patients ayant reçu de fortes doses d’anthracyclines seront atteints d’une insuffisance cardiaque dans les 20 années suivant le traitement. Les adultes traités par le trastuzumab sont exposés à un risque de cardiomyopathie habituellement réversible. Jusqu’à 12 % des adultes traités par le trastuzumab et 20 % de ceux ayant également reçu une anthracycline présenteront une cardiotoxicité dans les 5 ans. Les facteurs de risque de cardiomyopathie comprennent les caractéristiques du patient (par ex., âge, sexe, prédispositions génétiques) et du traitement (p. ex., dose cumulative d’anthracycline). La radiothérapie ciblant une région où se trouve le cœur augmente le risque de cardiomyopathie, de coronaropathie, de dysfonction valvulaire, d’arythmies et de maladie péricardique. Il existe des lignes directrices en matière de surveillance qui permettent d’orienter le suivi cardiaque à long terme chez les personnes ayant survécu à un cancer dans l’enfance, mais non chez celles ayant survécu à un cancer à l’âge adulte; ainsi, un suivi à intervalles réguliers pour dépister toute dysfonction cardiaque pourrait être une pratique raisonnable. Les facteurs de risque modifiables de maladie cardiaque, tels que l’hypertension, l’usage du tabac et la dyslipidémie, interagissent avec les traitements anticancéreux et augmentent, de ce fait, le risque de maladie cardiaque. La prise en charge de ces facteurs de risque revêt donc une importance accrue. La coordination des soins entre l’oncologue et le cardiologue optimiserait les soins chez les personnes exposées à un risque élevé de cardiotoxicité qui pourraient bénéficier d’une surveillance et de stratégies thérapeutiques appropriées.
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