SAN ANTONIO – The guideline-recommended practice of routinely measuring left ventricular ejection fraction before anthracycline-based chemotherapy to screen out patients at increased risk for treatment-induced heart failure has come under fire as unproductive and financially wasteful.
It’s a practice endorsed by the American Heart Association and American College of Cardiology, enshrined in Food and Drug Administration labeling, required as part of most U.S. clinical trials, and common in community-based oncology practice.
Yet there are no data to support the utility of this practice as a screening tool aimed at minimizing heart failure induced by anthracycline-based chemotherapy, according to a report at the San Antonio Breast Cancer Symposium.
Dr. Seema M. Policepatil of the Gundersen Lutheran Medical Foundation, La Crosse, Wis., and colleagues presented a retrospective study that suggested routine cardiac ejection fraction screening under these circumstances is without merit. The study included 466 patients with early-stage, HER2-negative invasive breast cancer who were under consideration for anthracycline-based chemotherapy as part of their initial therapy. None had prior heart failure.
Left ventricular ejection fraction (LVEF) was measured by echocardiography, nuclear imaging, or MRI prior to chemotherapy in 241 of the patients. This reflects institutional practice: at Gundersen, pretreatment assessment of cardiac pump function is common but not uniform.
One of the 241 patients was found to have asymptomatic left ventricular dysfunction, with a screening ejection fraction of 48%, and she therefore didn’t receive anthracycline-based chemotherapy. Thus, modification of the treatment strategy in response to screening of ejection fraction occurred only rarely.
In addition, nine patients – six who had pretreatment cardiac imaging and three who did not – skipped the chemotherapy, either because of physician or patient preference or participation in clinical trials.
During a mean 5 years of follow-up, 3 of the remaining 456 women were diagnosed with heart failure: 2 among those with a pretreatment LVEF measurement, and 1 among those without it. That’s an acceptably low 0.7% event rate, she declared.
Current practice guidelines recommending pretreatment LVEF measurement are based upon expert consensus. It’s time to incorporate the available evidence, which in the case of the Gundersen experience doesn’t support the practice, Dr. Policepatil continued.
Assuming that nationally half of all patients with early-stage HER2-negative breast cancer undergo measurement of their LV ejection fraction before getting chemotherapy, eliminating this routine practice would save $7 million to $17 million annually based upon Medicare and Medicaid reimbursement rates, the physician added.
This study was funded by the Center for Cancer and Blood Disorders at the Gundersen Lutheran Medical Foundation. Dr. Policepatil declared having no financial conflicts.