Can strain imaging predict cardiotoxicity in survivors of childhood cancer?
Jamie Harrington, MD
BACKGROUND: Anthracycline induced cardiotoxicity is one of the most serious adverse outcomes in childhood cancer survivors with delays in recognition and treatment resulting in decreased recovery of cardiac function. Strain imaging is a newer echocardiographic modality that, in 100% of studies, is able to detect decreased cardiac function earlier than conventional echocardiogram measures of function (ejection fraction and fractional shortening), and in adult studies, changes in strain during chemotherapy have been shown to predict which patients will develop future cardiotoxicity.
GAP: No studies have assessed the ability of strain to predict cardiotoxicity in children and strain is not being performed as routine surveillance, despite being done routinely by many adult providers. In addition, adult guidelines have been published recommending that strain should be performed routinely on all patients receiving anthracyclines and there are recommendations for modification of chemotherapy protocols and initiation of heart failure treatment based on strain parameters; these do not exist in children.
HYPOTHESIS: We aim to perform a prospective study monitoring cardiac function by strain imaging in pediatric oncology patients to determine if strain measurements are predictive of cardiotoxicity, similar to recent findings in studies with strain imaging in adult oncology patients. Our hypotheses are as follows:
• Myocardial strain decreases in children after treatment with anthracyclines and is associated with clinical variables such as cumulative anthracycline dose, gender, age, chest radiation, and dexrazoxane use.
• The change in strain from pre-to post-treatment with anthracyclines and the absolute strain at completion of chemotherapy are predictive of which children will develop cardiotoxicity within the first 12 months after anthracycline exposure.
METHODS: This will be a single center prospective study to monitor cardiac function by strain imaging in pediatric patients ( 18 years) with new oncologic diagnoses requiring anthracycline-containing chemotherapy at Columbia University Medical Center. Left ventricular strain measurements will be performed on each patient prior to initiation of anthracyclines, during, at completion, and at 6 and 12 months after anthracycline exposure with the primary outcomes being the change in strain at completion of anthracycline exposure and the development of cardiotoxicity.
IMPACT: If we show that strain is predictive of cardiotoxicity it will provide support for making strain imaging a routine part of cardiac surveillance in children treated with anthracyclines and will serve as rationale for larger trials aimed at determining screening stratification guidelines based on strain imaging as well as clinical trials aimed at cardioprotection. This will help providers identify children who require closer cardiac surveillance after chemotherapy completion and who may benefit from earlier treatment aimed at preventing cardiotoxicity.