American Society of Clinical Oncology Clinical Evidence Review on the Ongoing Care of Adult Cancer Survivors: Cardiac and Pulmonary Late Effects

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American Society of Clinical Oncology Clinical Evidence Review on the Ongoing Care of Adult Cancer Survivors: Cardiac and Pulmonary Late Effects

Joseph R. Carver, Charles L. Shapiro, Andrea Ng, Linda Jacobs, Cindy Schwartz, Katherine S. Virgo, Karen L. Hagerty, Mark R. Somerfield, and David J. Vaughn for the ASCO Cancer Survivorship Expert Panel

From the Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA; Ohio State University Comprehensive Cancer Center, Columbus, OH; Brigham and Women's Hospital, Boston, MA; Brown University, Providence, RI; St Louis University Medical Center & Department of Veterans Affairs Medical Center, St Louis, MO; and the American Society of Clinical Oncology, Alexandria, VA.

Purpose: To review the evidence on the incidence of long-term cardiac or pulmonary toxicity secondary to chemotherapy, radiotherapy, or trastuzumab in symptomatic and asymptomatic cancer survivors.

Methods: An American Society of Clinical Oncology Panel reviewed pertinent information from the literature through February 2006.

Results: Few studies directly addressing the benefits of screening for long-term cardiac or pulmonary toxicity in asymptomatic cancer survivors who received chemotherapy, radiotherapy, or trastuzumab were identified. The reviewed literature included primarily retrospective and cross-sectional studies describing the incidence of cardiac and pulmonary late effects. Anatomic and/or functional abnormalities have been associated with use of all currently available anthracyclines and their derivatives. Trastuzumab-related cardiac dysfunction rarely causes death, and in most cases is reversible with improvement in cardiac function on drug discontinuation and/or treatment with cardiac medications. The estimated aggregate incidence of radiation-induced cardiac disease is 10% to 30% by 5 to 10 years post-treatment, although the incidence may be lower with modern techniques. Radiation pneumonitis is reported in 5% to 15% of lung cancer patients receiving definitive external-beam radiation therapy. A minority of patients may develop progressive pulmonary fibrosis; late complications include cor pulmonale and respiratory failure. Bleomycin-induced pneumonitis is an acute rather than late effect of treatment. Late pulmonary complications in bone marrow or stem cell transplantation patients who develop interstitial pneumonitis include idiopathic pneumonia syndrome and bronchiolitis obliterans.

Conclusion: An increased incidence of cardiac and/or pulmonary dysfunction is observed in cancer survivors. Research is needed to identify high-risk patients, and to determine the optimal screening strategies and subsequent treatment.

Address reprint requests to American Society of Clinical Oncology, Cancer Policy and Clinical Affairs, 2318 Mill Road, Suite 800, Alexandria, VA 22314; e-mail: guidelines@asco.org.