Cancer and Blood Disorders Center, Seattle Children's Hospital, University of Washington, Seattle.
Fred Hutchinson Cancer Center, Seattle, Washington.
JAMA Netw Open. 2023 Dec 1;6(12):e2347449. doi: 10.1001/jamanetworkopen.2023.47449.
Cardiovascular disease is the leading noncancer cause of premature death among survivors of childhood cancer. Adult survivors of childhood cancer are largely managed by primary care practitioners (PCPs), and health care utilization patterns related to cardiovascular screening are not well described.
To examine screening and health care utilization among survivors of childhood cancer at high risk for cardiovascular complications.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter cross-sectional study included participants enrolled in a randomized clinical trial from 2017 to 2021. Abstracted documentation of participants' cancer history, cardiotoxic treatment exposures, and survivorship care plans were obtained from participants' PCPs spanning 2 years preceding trial enrollment. Participants were members of the Childhood Cancer Survivor Study cohort at elevated risk for ischemic heart disease or heart failure, enrolled in a randomized trial focused on improving cardiovascular risk factor control. Data were analyzed from November 2022 to July 2023.
Outcomes of interest were numbers of PCP and specialist visits, cardiovascular risk factors (hypertension, dyslipidemia, and diabetes), risk factor screening, and cardiac testing. Multivariable logistic regression assessed characteristics associated with up-to-date cardiac testing at enrollment.
Of 347 enrolled participants, 293 (84.4%) had evaluable medical records (median [range] age, 39.9 [21.5-65.0] years; 149 [50.9%] male) and were included in analyses. At baseline, 238 participants (81.2%) had a documented PCP encounter; 241 participants (82.3%) had undergone blood pressure screening, 179 participants (61.1%) had undergone lipid testing, and 193 participants (65.9%) had undergone diabetes screening. A total of 63 participants (21.5%) had echocardiography completed or planned. Only 198 participants (67.6%) had records referencing a cancer history. PCP documentation of prior cardiotoxic exposures was low compared with known exposures, including radiation therapy (103 participants [35.2%] vs 203 participants [69.3%]; P < .001) and anthracycline chemotherapy (27 participants [9.2%] vs 222 participants [75.8%]; P = .008). Few records referenced a need for cancer-related late effects surveillance (95 records [32.4%]). Independent factors associated with cardiac screening included documentation of increased cardiovascular disease risk (odds ratio [OR], 11.94; 95% CI, 3.37-42.31), a late-effects surveillance plan (OR, 3.92; 95% CI, 1.69-9.11), and existing cardiovascular risk factors (OR per each additional factor, 2.09; 95% CI, 1.32-3.31).
This cross-sectional study of adult survivors of childhood cancer at increased risk of cardiovascular disease found low adherence to recommended cardiac testing and documentation of risk for these individuals. Improving accuracy of reporting of survivors' exposures and risks within the medical record may improve screening.
心血管疾病是儿童癌症幸存者早逝的主要非癌症原因。儿童癌症幸存者主要由初级保健医生 (PCP) 管理，与心血管筛查相关的保健利用模式尚未得到很好的描述。
研究心血管并发症高危儿童癌症幸存者的筛查和保健利用情况。
设计、地点和参与者：这是一项多中心横断面研究，纳入了 2017 年至 2021 年参加随机临床试验的参与者。从参与者的 PCP 处获得了参与者癌症史、心脏毒性治疗暴露和生存者护理计划的文档记录，这些记录涵盖了试验入组前 2 年的情况。参与者是缺血性心脏病或心力衰竭风险升高的儿童癌症幸存者研究队列的成员，参加了一项专注于改善心血管风险因素控制的随机试验。数据于 2022 年 11 月至 2023 年 7 月进行分析。
感兴趣的结果是 PCP 和专家就诊次数、心血管风险因素（高血压、血脂异常和糖尿病）、风险因素筛查和心脏检查。多变量逻辑回归评估了与入组时最新心脏检查相关的特征。
在 347 名入组的参与者中，有 293 名（84.4%）有可评估的医疗记录（中位数[范围]年龄，39.9[21.5-65.0]岁；149[50.9%]为男性），并纳入了分析。基线时，238 名参与者（81.2%）有记录的 PCP 就诊；241 名参与者（82.3%）接受了血压筛查，179 名参与者（61.1%）接受了血脂检测，193 名参与者（65.9%）接受了糖尿病筛查。共有 63 名参与者（21.5%）完成或计划进行超声心动图检查。只有 198 名参与者（67.6%）的记录中提到了癌症史。与已知的暴露情况相比，PCP 记录的既往心脏毒性暴露情况较低，包括放疗（103 名参与者[35.2%]与 203 名参与者[69.3%]；P < .001）和蒽环类化疗（27 名参与者[9.2%]与 222 名参与者[75.8%]；P = .008）。很少有记录提到需要进行癌症相关的晚期效应监测（95 份记录[32.4%]）。与心脏筛查相关的独立因素包括心血管疾病风险增加的记录（比值比[OR]，11.94；95%置信区间[CI]，3.37-42.31）、晚期效应监测计划（OR，3.92；95%CI，1.69-9.11）和现有的心血管风险因素（每个额外因素的 OR，2.09；95%CI，1.32-3.31）。
这项针对心血管疾病风险增加的儿童癌症幸存者的横断面研究发现，对推荐的心脏检查的依从性较低，且对这些个体的风险记录不足。提高医疗记录中对幸存者暴露和风险的报告准确性可能会改善筛查。
