Cardiovascular disease in adult survivors of childhood cancer

Abstract

Treatment advances have increased survival in children with cancer, but subclinical, progressive, irreversible, and sometimes fatal treatment-related cardiovascular effects may appear years later. Cardio-oncologists have identified promising preventive and treatment strategies. Dexrazoxane provides long-term cardioprotection from doxorubicin-associated cardiotoxicity without compromising the efficacy of anticancer treatment. Continuous infusion of doxorubicin is as effective as bolus administration in leukemia treatment, but no evidence has indicated that it provides long-term cardioprotection; continuous infusions should be eliminated from pediatric cancer treatment. Angiotensin-converting enzyme inhibitors can delay the progression of subclinical and clinical cardiotoxicity. All survivors, regardless of whether they were treated with anthracyclines or radiation, should be monitored for systemic inflammation and the risk of premature cardiovascular disease. Echocardiographic screening must be supplemented with screening for biomarkers of cardiotoxicity and perhaps by identification of genetic susceptibilities to cardiovascular diseases; optimal strategies need to be identified. The health burden related to cancer treatment will increase as this population expands and ages.

Keywords: etiology; prevention; screening; treatment.

Figure 1

Stages in the course of pediatric ventricular dysfunction. These stages can be monitored by echocardiographic measurements of left ventricular structure and function in combination with concentrations of validated cardiac biomarkers. Risk factors and high-risk populations for ventricular dysfunction are highlighted where preventive or early therapeutic strategies may be effective. Determining the cause of dysfunction may suggest cause-specific therapies. The circled numbers 1–5 indicate points of preventive or therapeutic interventions and where biomarker measurements may be helpful. Abbreviations: ECMO, Extracorporeal Membrane Oxygenation; VAD, Ventricular Assist Device. Figure reprinted from Reference 101 with permission from Oxford University Press.