How frequently should childhood cancer survivors be screened for effects of cardiac toxicities?
The answer to that question can be found in the consensus-based Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adults Cancers, which have been widely followed for more than a decade. The guidelines recommend periodic lifetime screening “based on age at treatment, cumulative anthracycline dose, and whether the heart was irradiated,” wrote Richard M. Steingart, MD, Memorial Sloan Kettering Cancer Center, New York, NY, in an editorial in published in the journal Annals of Internal Medicine.1
However, two models of the clinical and economic effects of using these guidelines have now concluded that less frequent screening would achieve the same benefits and reduce costs.
Although survivors of childhood cancers comprise less than 1% of the nearly 14 million cancer survivors in the United States, the risk for late effects has been well-characterized by the Childhood Cancer Survivor Study (CCSS); both current studies used this as a source of self-reported congestive heart failure (CHF) data.2, 3
The Wong et al study design was a simulation of life histories using Markov health states.3 “Excessive screening wastes scarce financial resources, whereas inadequate screening delays ALVD [asymptomatic left ventricular dysfunction] treatment,” they wrote. “The purpose of this study was to determine the efficacy and cost-effectiveness of the COG guidelines and to explore alternative screening schedules that might be more cost-effective.”
They examined the effect of echocardiographic screening followed by angiotensin-converting enzyme (ACE) and beta-blocker therapies after a diagnosis of ALVD. Outcome measures were quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios in dollars by QALY, and cumulative incidence of heart failure.
Use of the COG guidelines “could reduce the risk for heart failure in survivors at less than $100,000/QALY,” Wong and colleagues reported. However, “less frequent screening achieves most of the benefits and would be more cost effective than the COG guidelines,” as well as being less burdensome to patients. They recommended the following: “annual screening…for more than 50% of survivors could be decreased to every 2 to 4 years. The biennial screening recommended for more than 30% of survivors may be decreased to every 5 years. Screening every 5 years, recommended for 3% of survivors, could be maintained, but the frequency could be reduced to 10 years for an additional 12% of the survivors.”