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Chest Radiation Cancer Patients Should Undergo CV Screening Every 5-10 Years

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According to the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC) and the American Society of Echocardiography (ASE) cancer patients who are given chest radiation should be screened for heart disease every 5 to 10 years or so.

Published in European Heart Journal - Cardiovascular Imaging.1, their recommendations are presented in the very first consensus statement on screening for radiation-induced heart disease (RIHD).

"The prevalence of radiation-induced heart disease is increasing because the rate of cancer survival has improved. It's a long term risk, and RIHD manifests 5-20 years after the radiation dose,” said chair of the expert task force and president of the EACVI, Professor Patrizio Lancellotti.

"Survivors of Hodgkin's lymphoma and breast cancer received high doses of radiation on their chest under the old treatment regimes. Over time these patients can develop RIHD in the heart valves, myocardium, vessels including the aorta, the pericardium, and the coronary arteries. Their risk of death from coronary artery disease, myocardial ischemia and myocardial infarction is increased,” added Lancellotti.breast cancer radiotherapy

He went on to say, "Radiotherapy is now given in lower doses but patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer and oesophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke."

RIHD is expected to take place in 10-30% of patients who are given chest radiotherapy within 5-10 years following treatment. Cardiac structural and functional changes after radiation can be identified early using echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance (CMR) and nuclear cardiology. However, screening for RIHD has never been common practice.

In the report, experts detail that:

-    Before initiating any chest radiotherapy, patients should have screening for RIHD risk factors, a clinical examination, and a baseline echocardiographic evaluation.

-    Patients who receive chest radiation for cancers including breast cancer or lymphoma should receive cardiac screening 5 years post-treatment if they have any cardiac abnormality or are at high risk and 10 years post-treatment if not.

-    Cardiovascular screening should be repeated every 5-10 years depending on the presence of cardiac abnormalities and the level of risk.

-    All patients who had chest radiation for cancer in the past should receive a cardiac examination starting with echocardiography.

Patients are put at a greater risk of having RIHD if they have radiation for left-sided breast cancer, have a high dose of radiation (often used in young people), the irradiated area is not shielded, have a high dose of anthracyclines (chemotherapy), or have cardiovascular risk factors including smoking, obesity and inactivity.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. Cardiovascular screening is needed before and after radiation therapy to detect RIHD early, follow up patients at appropriate intervals, and define the optimal timing for any kind of intervention,” said Lancellotti.

Lacellotti also noted that while echocardiography is the first line of imaging assessment, other examinations including stress imaging, CT, and CMR are required to appropriately evaluate the presence of myocardial fibrosis using CMR and more precisely calculate cardiac calcification using CT.

"A registry of RIHD is needed in Europe to determine the true prevalence of the disease and collect outcome data. This together with screening should reduce the risk of patients developing RIHD and enable us to treat it early when it does occur,” he concluded.

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