Global variability in cardiovascular care of pediatric cancer patients and survivors: survey results from the International Cardio Oncology Society (ICOS)

Abstract

Childhood cancer survivors (CCS) are at elevated risk for cardiovascular disease due to cardiotoxic cancer therapies. Different international guidelines and recommendations for follow-up were published. However, global practices surrounding cardiovascular risk assessment, screening, and management in CCS remain variable and incompletely characterized. A 20-question survey was created by the Pediatric Working Group of the International Cardio-Oncology Society (ICOS) for medical practitioners involved in the care of CCS to assess current practices in cardiovascular risk evaluation, preventive strategies, screening modalities, cardiology referral, and heart failure (HF) management. The survey distribution was a collaborative effort by ICOS pediatric work group leaders. Descriptive statistics were used to summarize responses. A total of 123 unique practitioners responded, with 75% identifying as pediatric specialists. Most respondents worked in cardiology (72%). Respondents represented both low- and middle-income countries (LMICs, 63%) and high-income countries (HICs, 36%). The majority routinely discussed cardiovascular test results (89%) and addressed hypertension (74%) and obesity (68%) with patients, but lipid discussions were less common (57%). Oncologists were more likely than cardiologists to emphasize cardiotoxicity risks like anthracycline dose and thoracic radiation. Cardioprotective strategies included lifestyle modifications (56%) and dexrazoxane use (45%), with lower uptake of preemptive beta blockers (16%) or ACE inhibitors (18%), particularly in LMICs. Cardiac screening practices included EKG (85%), 2D echocardiography (62%), and myocardial strain imaging (54%). Advanced imaging (e.g., cardiac MRI, 18%) was more common in HIC. Referral to cardiology was most frequently triggered by asymptomatic left ventricular (LV) dysfunction (33%), with exclusively radiation-related referrals being rare. HF management predominantly included angiotensin-converting enzyme inhibitors (ACEi) (76%) and beta blockers (59%), with limited use of mineralocorticoid receptor antagonists (MRAs) (9%) or angiotensin receptor/neprilysin inhibitors (ARNIs) (7%). Statin use was infrequent (10% routinely), with most prescribing based on abnormal lipid panels (35%). This global survey highlights an urgent need for standardized cohesive, global, standardized approaches to cardiovascular management in CCS. This study reveals significant variability in cardiovascular risk discussions, screening, and HF management for CCS, with differences by specialty and resource setting.