It’s long been known that survivors of childhood cancer face elevated risk of cardiovascular complications related to cancer therapies. Among these there’s a 1 in 4 chance of developing cardiomyopathy by age 45, and a 5% chance of heart failure. In some cases, heart problems appear in early childhood or while receiving cancer treatments.
Yet fewer than 5% of medical centers offer comprehensive cardio-oncology services for children, according to a 2019 American College of Cardiology survey.
In many settings, pediatric cardiologists join a care team only after tests show a child has a heart problem. To address this oversight in care, Children’s Medical Center Dallas, part of Children’s HealthSM created one of the nation’s first Pediatric Cardio-Oncology Programs, offering multidisciplinary care.
“Ideally, we assess a child’s heart health before they start cancer treatments,” says Nathanya Baez Hernandez, M.D., Pediatric Cardiologist at Children’s Health and Associate Professor at UT Southwestern. “This approach provides a baseline for future comparison. If needed, we start cardiac therapies to optimize cardiac care before cancer treatment. This allows us to start post cancer therapy interventions early before heart damage can become severe.”
Here are a few elements of the Cardio-Oncology Program at Children’s Health that are improving patient outcomes. Many of these approaches are easily adaptable, even if your center doesn’t have a dedicated program.
Identifying who needs cardio-oncology care
The cardio-oncology team developed a risk-stratification screening process to identify patients at high risk for cardiovascular disease. During screening we assess:
Cancer type: Patients with blood cancers, sarcomas and Wilms tumors are most at risk for cardiotoxicity.
Cancer treatments, dosage and length: If a patient has or is undergoing any of the following treatments: cardiotoxic chemotherapy, radiation therapy to the chest, immunotherapies and targeted therapies.
Cardiac history: A patient’s medical history is reviewed to determine prior heart disease or potential symptoms of heart disease.
Cardiovascular disease risk factors: We assess whether a child has obesity, hypertension and/or high cholesterol.
Based on the screening, the team places a patient in one of the following categories which is relevant for further follow up:
Screening population: These patients are at risk for cardiotoxicity based on cancer treatment history – but currently do not have evidence of cardiac dysfunction or other cardiovascular problems. They receive educational counseling about heart disease risk factors and prevention. They may also get nutritional and psychological counseling if needed. These patients return to the Cardio-Oncology Clinic for heart tests about two years after completing cancer treatments, which is usually when the transition to the survivorship After Cancer Experience (ACE) Program takes place.
Early intervention group: These patients have mild subclinical cardiotoxicity and will need closer follow up and in some cases heart medications. They receive educational, nutritional and psychological counseling.
Heart failure group: These patients have moderately or severely depressed cardiac function, or symptomatic heart failure. They receive care at a dedicated Pediatric Cardiac-Oncology Heart Failure Clinic.
Streamlining cardio-oncology services for families
One benefit of having a dedicated Cardio-Oncology Program is that it makes it easier for patients to receive all the care they need during one clinic visit. “We housed the Cardio-Oncology Clinic at the Pauline Allen Gill Center for Cancer and Blood Disorders because our families were familiar with the location,” says Daniel Bowers, M.D., Medical Director of pediatric neuro-oncology at Children’s Health and Professor of Pediatrics and Neurological Surgery at UT Southwestern.
At the start of each clinic visit, families receive a “roadmap” explaining what tests to expect and which providers they’ll see. Every clinic visit begins with the child getting cardiac imaging which may include an echocardiogram, electrocardiogram and other cardiac tests on the cardiology floor. They then move to the Pauline Allen Gill Center for Cancer and Blood Disorders to get blood tests, which help guide their post-cancer follow-up and recommended heart treatments. Patient then meet with the care team at the Cardio-Oncology Clinic.
Providing a multidisciplinary approach to care
The cardio-oncology care team at Children’s Health brings together a variety of providers who take a holistic approach to addressing the complex issues that can arise for patients with these separate, but interlinked, health conditions. Pediatric cardiologists with expertise in cardiomyopathy and pediatric oncologists with expertise in survivorship work with:
Advanced practice providers, nurses and a program coordinator who guide families through the care journey. “We see patients at every clinic visit, which helps us develop strong relationships that continue through the transition to adult survivorship,” says pediatric oncology nurse practitioner Cynthia Cochran, A.P.R.N.
Pediatric registered dietitian nutritionists who help children adopt heart-healthy eating habits. “In our Cardio-Oncology practice, around 45% of our pediatric cancer survivors have obesity, high cholesterol and/or hypertension,” says Dr. Baez Hernandez. Nutritional counseling may be able to impact the modifiable cardiac risk factors.
Pediatric psychologists who screen for anxiety, depression and other concerns. Studies suggest that psychological services are more important for intensively-treated, high-risk survivors who have serious, late-treatment complications such as cardiotoxicity.
Additional specialists including electrophysiologists, interventional cardiologists and cardiothoracic surgeons – who provide advanced cardiac support. “Some children need interventions such as ventricular assist devices or ECMO to help their hearts recover during or after cancer treatments,” says Dr. Baez Hernandez. A few patients have received – or are awaiting – heart transplants.
“Our goal with this program is to ensure successful pediatric cancer survivorship care while maintaining heart health to allow survivors to enjoy all that life has to offer, now and well into the future,” she says.
Why Children’s Health for pediatric cardio-oncology care
Children’s Health ranks among the nation’s best medical centers for pediatric cardiology and pediatric oncology. The pediatric Cardio-Oncology team sees approximately 10 patients at every monthly multidisciplinary clinic and is experiencing a significant number of referrals for evaluation of patients undergoing cancer treatments. Over 150 patients have participated in the program since its launch in late 2020. Team members also published a Cardio-Oncology article that provides more information.
Learn more about the Pediatric Cardio-Oncology Program at Children’s Health.
