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Survivorship After Cancer
LETTER
Survivorship After Cancer To The Editor: We have read with interest the article by Flores-Umanzor et al,1 which discussed a case of radiation-induced valvular disease after mantle radiation. Valvular disease, cardiomyopathy, and accelerated atherosclerosis are well-documented late complications of chest radiation, especially when performed in the adolescent population. It is well documented that the cumulative incidence of cardiac disease is related to mediastinal radiation dose; however, appropriate follow-up for these patients to assess for radiation-induced cardiotoxicity is unclear.2 Cancer survivorship clinics currently do not have standardized guidelines to monitor for cardiomyopathy and valvular disease, likely because each patient received a different radiation dose.3 A cross-sectional study of 82 subjects evaluated the presence of valvular disease in Hodgkin’s lymphoma survivors treated with mediastinal radiotherapy. In this study, severe valvular disease was found in 24.5% of survivors who received radiation, compared with 3.4% without radiation. Additionally, much like the patient mentioned above, aortic regurgitation was the most prevalent valvular disorder.4 The Stanford Group, in the largest prospective study in Hodgkin’s lymphoma survivors, found that 10-year cardiovascular follow-up was beneficial in diagnosing cardiomyopathy and atherosclerotic disease.5 Cardiac screening included rest and stress echocardiography, as well as nuclear scintigraphy. Current Children’s Oncology Group recommendations for cardiovascular health screening after radiation include minimizing cardiac risk factors and referral to a cardiologist for baseline evaluation after completion of treatment.6 The National Comprehensive Cancer Network recommends an echo or multigated acquisition scan every Funding: None. Conflict of Interest: None. Authorship: All authors had a role in drafting the letter, including the final version submitted for publication.
0002-9343/$ -see front matter Ó 2017 Elsevier Inc. All rights reserved.
1 to 2 years after radiation, but the frequency depends on age of exposure and total dose of radiation.7 There is a clear benefit of routine cardiology follow-up to evaluate for cardiotoxicities of radiation. A suggestion would be to combine cardiac screening with cancer survivorship clinics. Although it was unclear whether the patient discussed by Flores-Umanzor et al underwent appropriate cardiac screening or whether she was followed by a cardiologist, she may have benefited from earlier, more frequent echocardiography to diagnose her cardiomyopathy.1 Jori L. Kaplan, Jaymin A. Patel, Poorvi K. Desai, Emilie Y. Wang,
MD MD MD MD
Department of Internal Medicine University of South Florida Morsani College of Medicine Tampa
http://dx.doi.org/10.1016/j.amjmed.2017.03.036
References 1. Flores-Umanzor EJ, Hernandez-Enriquez M, Caldentey G, et al. Radiation-induced cardiac valve disease. Am J Med. 2017;130(3):e99-e100. 2. Schellong G, Riepenhausen M, Bruch C, et al. Late valvular and other cardiac diseases after different doses of mediastinal radiotherapy for Hodgkin disease in children and adolescents: report from the longitudinal GPOH follow-up project of the German-Austrian DAL-HD studies. Pediatr Blood Cancer. 2010;55(6):1145-1152. 3. Jaworski C, Mariani JA, Wheeler G, Kaye DM. Cardiac complications of thoracic irradiation. J Am Coll Cardiol. 2013;61(23):2319-2328. 4. Bijl JM, Roos MM, van Leeuwen-Segarceanu EM, et al. Assessment of valvular disorders in survivors of Hodgkin’s lymphoma treated by mediastinal radiotherapy chemotherapy. Am J Cardiol. 2016;117(4):691-696. 5. Heidenreich PA, Hancock SL, Lee BK, et al. Asymptomatic cardiac disease following mediastinal irradiation. J Am Coll Cardiol. 2003;42(4):743-749. 6. Children’s Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancer (version 4.0October 2013). Available at: www.survivorshipguidelines.org/pdf/ LTFUGuidelines_40.pdf. Accessed March 10, 2017. 7. National Comprehensive Cancer Network. Adolescent and young adult oncology (version 2.2017). Available at: www.nccn.org/professionals/ physician_gls/pdf/aya.pdf. Accessed March 10, 2017.
Survivorship After Cancer To The Editor: We have read with interest the article by Flores-Umanzor et al,1 which discussed a case of radiation-induced valvular disease after mantle radiation. Valvular disease, cardiomyopathy, and accelerated atherosclerosis are well-documented late complications of chest radiation, especially when performed in the adolescent population. It is well documented that the cumulative incidence of cardiac disease is related to mediastinal radiation dose; however, appropriate follow-up for these patients to assess for radiation-induced cardiotoxicity is unclear.2 Cancer survivorship clinics currently do not have standardized guidelines to monitor for cardiomyopathy and valvular disease, likely because each patient received a different radiation dose.3 A cross-sectional study of 82 subjects evaluated the presence of valvular disease in Hodgkin’s lymphoma survivors treated with mediastinal radiotherapy. In this study, severe valvular disease was found in 24.5% of survivors who received radiation, compared with 3.4% without radiation. Additionally, much like the patient mentioned above, aortic regurgitation was the most prevalent valvular disorder.4 The Stanford Group, in the largest prospective study in Hodgkin’s lymphoma survivors, found that 10-year cardiovascular follow-up was beneficial in diagnosing cardiomyopathy and atherosclerotic disease.5 Cardiac screening included rest and stress echocardiography, as well as nuclear scintigraphy. Current Children’s Oncology Group recommendations for cardiovascular health screening after radiation include minimizing cardiac risk factors and referral to a cardiologist for baseline evaluation after completion of treatment.6 The National Comprehensive Cancer Network recommends an echo or multigated acquisition scan every Funding: None. Conflict of Interest: None. Authorship: All authors had a role in drafting the letter, including the final version submitted for publication.
0002-9343/$ -see front matter Ó 2017 Elsevier Inc. All rights reserved.
1 to 2 years after radiation, but the frequency depends on age of exposure and total dose of radiation.7 There is a clear benefit of routine cardiology follow-up to evaluate for cardiotoxicities of radiation. A suggestion would be to combine cardiac screening with cancer survivorship clinics. Although it was unclear whether the patient discussed by Flores-Umanzor et al underwent appropriate cardiac screening or whether she was followed by a cardiologist, she may have benefited from earlier, more frequent echocardiography to diagnose her cardiomyopathy.1 Jori L. Kaplan, Jaymin A. Patel, Poorvi K. Desai, Emilie Y. Wang,
MD MD MD MD
Department of Internal Medicine University of South Florida Morsani College of Medicine Tampa
http://dx.doi.org/10.1016/j.amjmed.2017.03.036
References 1. Flores-Umanzor EJ, Hernandez-Enriquez M, Caldentey G, et al. Radiation-induced cardiac valve disease. Am J Med. 2017;130(3):e99-e100. 2. Schellong G, Riepenhausen M, Bruch C, et al. Late valvular and other cardiac diseases after different doses of mediastinal radiotherapy for Hodgkin disease in children and adolescents: report from the longitudinal GPOH follow-up project of the German-Austrian DAL-HD studies. Pediatr Blood Cancer. 2010;55(6):1145-1152. 3. Jaworski C, Mariani JA, Wheeler G, Kaye DM. Cardiac complications of thoracic irradiation. J Am Coll Cardiol. 2013;61(23):2319-2328. 4. Bijl JM, Roos MM, van Leeuwen-Segarceanu EM, et al. Assessment of valvular disorders in survivors of Hodgkin’s lymphoma treated by mediastinal radiotherapy chemotherapy. Am J Cardiol. 2016;117(4):691-696. 5. Heidenreich PA, Hancock SL, Lee BK, et al. Asymptomatic cardiac disease following mediastinal irradiation. J Am Coll Cardiol. 2003;42(4):743-749. 6. Children’s Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancer (version 4.0October 2013). Available at: www.survivorshipguidelines.org/pdf/ LTFUGuidelines_40.pdf. Accessed March 10, 2017. 7. National Comprehensive Cancer Network. Adolescent and young adult oncology (version 2.2017). Available at: www.nccn.org/professionals/ physician_gls/pdf/aya.pdf. Accessed March 10, 2017.