Study Calls for Revisiting Guidelines for Screening Childhood Cancer Survivors at Risk of Congestive Heart Failure


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Lisa Diller, MD

Jennifer Yeh, PhD

One of the first studies to analyze the effectiveness of screening survivors of childhood cancer for early signs of impending congestive heart failure found improved health outcomes but suggests that less frequent screening than currently recommended may yield similar clinical benefit. The researchers, in a study published in the Annals of Internal Medicine,1 utilized a simulation-based model to estimate the long-term benefits associated with routine screening.

The current guidelines recommend that survivors treated with chemotherapy agents known to affect long-term heart health be screened as often as every year, with a schedule dependent on their level of congestive heart failure risk. The new study suggests that screening survivors less often may be nearly as effective in detecting heart disease early.

“It is important to monitor survivors so we can reduce the late effects of treatment whenever possible, but we may be asking them to be tested too often, which burdens both individuals and the health-care system,” said senior author Lisa Diller, MD, Chief Medical Officer of Dana-Farber/Boston Children’s Cancer and Blood Disorders Center. “We think it is worthwhile to review the current [congestive heart failure] screening guidelines.”

“Our findings suggest that there is a long-term benefit in screening survivors at elevated risk for [congestive heart failure],” said lead author Jennifer Yeh, PhD, of the Center for Health Decision Science at Harvard School of Public Health. “Yet less frequent screening than currently recommended may be reasonable when other factors are considered. We hope these results can help inform the ongoing discussion about screening childhood cancer survivors.”

The Children’s Oncology Group (COG) currently recommends that survivors undergo screening by echocardiography for asymptomatic left-ventricular dysfunction. If left untreated, this clinically silent condition can progress to congestive heart failure. COG recommends that patients at high risk of developing congestive heart failure be screened every 1 or 2 years and those at low risk be screened every 2 or 5 years.

Virtual Cohort

To estimate the clinical benefits and cost-effectiveness of the current heart screening guidelines, Drs. Diller and Yeh and their coauthor, cardiologist Anju Nohria, MD, of Brigham and Women’s Hospital, constructed a computer model of a virtual cohort of 15-year-olds who had survived cancer at least 5 years. Using data from the Childhood Cancer Survivors Study and the Framingham Heart Study, the researchers modeled the cohort’s congestive heart failure risk and clinical progression over the course of survivors’ lifetimes. Their analysis suggests that routine screening may prevent as many as 1 in 12 cases of congestive heart failure.

The authors then used Medicare data to estimate the costs and value (expressed in cost per quality-adjusted life year [QALY]) of different screening schedules (ie, every 1, 2, 5 or 10 years) and methods (echocardiography vs cardiac magnetic resonance imaging [MRI]) for the different congestive heart failure risk groups (ie, low, high).

At a cost-effectiveness threshold of $100,000/QALY, the model’s results indicate that echocardiographic screening might not be the best value for resources invested to reduce lifetime congestive heart failure risk among survivors at low risk of developing the disease. On the other hand, the data suggest that biennial echocardiography screening may be a high-value strategy for high-risk survivors. ■

Disclosure: For full disclosures of the study authors, visit annals.org.

Reference

1. Yeh JM, et al:  Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors. Ann Intern Med 160:661-671, 2014.



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