Cardioncology of children's patients: an interdisciplinary approach to treatment and supportive therapy

Nadir D. Zamaldinov, Sayna A. Malamagomedova, Aleksandr O.Kelin. Cardioncology of children’s patients: an interdisciplinary approach to treatment and supportive therapy. Cardiom-etry; Issue 23; August 2022; p. 54-57; DOI: 10.18137/cardiom-etry.2022.23.5457; Available from: issues/no23-august-2022/cardioncology-childrens-patients

Every year, about 400,000 children and adolescents aged from birth to 19 years get sick with various oncological diseases [1]. Among the most common oncological ailments that affect children are leukemia, malignant brain tumors, lymphomas as well as neuroblastoma and nephroblastoma [2]. Under the modern conditions, when the pace of development of innovative medical technologies is quite high, remission occurs in 75-80% of children. However, an increase in the survival rate of children receiving the necessary treatment after an oncological diagnosis is accompanied by an increase in the occurrence rate of concomitant various cardiovascular complications, which act as the main cause of the subsequent deterioration of well-being and mortality of underage patients [3]. In this regard, various interdisciplinary approaches that highlight the methods of treatment and supportive therapy of such patients are highly relevant. An analysis of these approaches is the purpose of this work.

Materials and methods

The paper analyzes the sources on the topic of the study, taking into account the reflection in those sources of modern approaches in the field of treatment and supportive therapy of children’s patients who also have problems in the field of cardiology. The collected material was analyzed by means of analytical and comparative research methods.

Results

One of the complications of the treatment of childhood cancer is myocardial toxicity. The appeal to this problem took place back in the 1960s, when anthra-cyclines were included in the treatment of childhood cancer [4]. It has been determined that these drugs lead to cardiac dysfunction of patients. In this regard, it has been decided to conduct visualization monitoring in children receiving anthracycline treatment in order to identify abnormalities in the field of heart function.

After that, already in the early 90s of the twentieth century, the issues of cardiotoxicity of those and similar groups of drugs began to be raised by researchers on an ongoing basis, in connection with which it was proposed to use improved means of visualizing the disease picture, serum biomarkers for stratification of cancer patients at risk of developing cardiopathologies [5].

The issues of preventing complications during the use of chemotherapy in the treatment of children with cancer began to be given priority attention, since cardiotoxicity was recognized as one of the most frequent complications in that group of patients. To this end, a thorough examination of patients was carried out to identify concomitant diseases and predisposition to cardiological diseases by obtaining a complete personal or hereditary history of patients. It was also determined the need for reproducible cardiovisualizations, in which the initial and longitudinal profiles were studied, including physical examination of the condition of patients, monitoring of vital signs and cardiac biomarkers before, during and after treatment or planning such for oncological diseases.

The risk of developing cardiopathologies can be determined by the nature of cancer, domains associated with therapy, concomitant diseases, the state of the cardiovascular reserve at the initial level, hereditary aspects in the field of cardiological diseases as well as features of the work of other organs and systems.

Given the wide range of therapeutic options (for example, chemotherapy, immunotherapy, radiation, stem cells, transplantation, surgery and targeted therapy), it is difficult to determine a single algorithm for the above screening, for this reason, the standard examination options in the section under consideration are usually visualizations of cardiovascular diseases (echocardiography or magnetic resonance visualizations of the heart, electrocardiography) the basic metabolic panel is also being investigated, and, in many cases, a basic map of biomarkers of cardiological diseases is being compiled [6 - 10].

Conventionally, cardiotoxicity is diagnosed by echocardiography when there is a 10% decrease in the LV ejection fraction (LVEF). This is the only marker of the ventricular dysfunction that allows us to determine the suboptimal outlines of cardiac remodeling in the preclinical stage of the disease. However, it is impossible to detect the presence of this marker using this method. For this reason, experts suggest using new visualizations methods, such as 3D scanning, deformation analysis and MRI, along with 2D echocardiography. This topic is of great importance, since the combination of these methods will reveal previously underestimated cardiovascular injuries which prevent adequate oncological treatment. Such pathologies include heart failure with a preserved ejection fraction, a form of cardiastolic insufficiency associated with diastolic dysfunction etc. Timely diagnosis of diastolic dysfunction is the key to preventing the progression of arrhythmia, cardiopulmonary mechanical deterioration and myocardial fibrosis [11].

Another reason for the appearance of cardiopathologies in children with cancer is the occurrence of vascular pathology under the influence of the toxicity of prescribed drugs. Orientation to endothelial factors as antitumor therapy, an introduction of high doses of steroids etc. cause the development of endothelial dysfunction and vascular hypercontractivity in such children.

The researchers note that the most common reasons for referring pediatric patients with cancer to cardiologists are:

– diastolic dysfunction;

– arrhythmias;

– systolic dysfunction;

– systemic arterial hypertension;

– pericardial disease;

– thromboembolic phenomena;

– pulmonary arterial hypertension [12].

In order to provide adequate medical measures to be taken in the field of providing care to oncolog-ically ill children suffering from cardiopathology and drug loading to be optimal, experts suggest dividing patients into 4 groups after the examination. The first group should include patients at a risk of cardiovascular toxicity; the second group should include patients with signs of cardiotoxicity in preclinical studies (asymptomatic phase); the third group should include patients with mild and moderate cardiovascular symptoms, and the fourth group will include patients in need of inpatient treatment. Such an approach will make it possible to provide the necessary assistance to this sort of patients in a timely manner, taking into account the assessment of their condition and constant medical monitoring.

Prevention of cardiopathologies in children with cancer begins from the moment of cancer diagnosis, since an early recognition serves to mitigate side effects from the use of chemotherapy and radiotherapy, which is of paramount importance to counteract intermediate and long-term cardiovascular consequences [13].

According to the researchers, the approach to developing a strategy of preventive and therapeutic measures also includes the division of patients into two main categories: patients receiving primary prevention (group 1) and those with severe cardiopathologies requiring secondary type therapy (groups 2-4).

Primary prevention strategies begin with a comprehensive assessment of concomitant diseases, risk factors (for example, emphasizing the importance of weight control, physical and dietary rehabilitation).

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Not only doctors should take part in this process, but also nutritionists, nurses, physiotherapists, pharmacists and other specialists who participate in the rehabilitation process of an underaged patient.

In addition, alternative therapies, such as liposomal therapy, which reduces cardiotoxic effects, should be used in the treatment of the patients, if possible. Additional recommendations include the use of slow infusion rates instead of bolus administration of anth-racyclines to reduce their accumulation in the myocardium [14].

There is also an opinion about the effectiveness of the use of dexrazoxane in this section, which is a chelating agent that reduces the production of iron-induced free radicals and induces degradation of topoisomerase IIb to reduce anthracycline-associated myocardial and endothelial damage.

Secondary prevention strategies include continuous screening options and are mainly dictated by individual treatment protocols for children undergoing cancer treatment in the active stage or at the stage of early or follow-up after completion of therapy.

Discussion

It is also necessary to consider various types of examination and medical care that are necessary for pediatric patients with oncological diagnoses suffering from cardiopathologies.

Inpatient care is one of the most important areas of this type of care. Here, the joint work of oncologists and cardiologists is important, who must timely identify possible pathologies and carry out their prevention and treatment.

The introduction of outpatient practice for such patients is also very important, since children who have received anti-cancer treatment require frequent follow-up during their therapy and after it. Of paramount importance is the training of pediatric cardiologists who have an idea of the spectrum of antitumor treatments and their associated detoxicity [15]. In addition, it is necessary to constantly conduct examinations for such children which include echocardiograms, electrocardiograms and outpatient monitoring. Cardiopulmonary stress tests and MRI are also important in this direction [16].

It should be said that the frequency of visits to polyclinics and imaging assessments depends both on the severity of the patient’s cardiac dysfunction and the timing and nature of cancer therapy [17].

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Taking into account all of the above, improved rates of childhood survival in oncological diseases have been achieved over the past decades, mainly due to an increase in therapeutic capabilities and the inclusion of a systematic multidisciplinary approach to supportive therapy. With the rapid development of anti-cancer methods, early diagnostics of cardiovascular diseases and the long-term consequences of certain types of therapy, it became necessary to develop cooperation between specialists from different fields of pediatrics [18]. The reason for this was the following factors:

• 1.    The practice of caring for children with cancer does not contain carefully developed approaches in the field of diagnosis of subclinical lesions of the cardiovascular system caused by cancer therapy.

• 2.    Advanced imaging techniques or complex biomarkers for monitoring adverse effects are often not implemented.

• 3.    The genetic predisposition of children with cancer to cardiological diseases remains insufficiently studied.

• 4.    Insufficient attention is paid to the elimination of the consequences of benign hematological diseases, which are known as chronic organ damage, although such consequences lead to an increase in morbidity and mortality in children.

The solution to these problems is seen addressing several directions.

• 1.    Improving the quality of treatment of the considered group of patients. In the process of providing medical care to such children, specialists of various profiles should take part, who are able to comprehensively assess the health status of such children in a continuous monitoring mode.

• 2.    The inclusion of a multidisciplinary cardionco-logical approach in the practice of treating the group of patients under consideration. This should include holding various types of consultations and consultations of specialists of various profiles, both off- and on-line. Interdisciplinary forums will also be quite valuable in this context, which will enable specialists to discuss various issues within the framework of solving the problem of treating children with oncological diseases and concomitant cardiopathologies.

• 3.    Implementation of administrative support. This aspect should be taken into account by the heads of medical organizations, since without the support of an administrative resource, the introduction of advanced diagnostic and treatment technologies is impossible.

• 4.    Organization of professional retraining. It is necessary to enable specialized experts to get acquainted with innovations in the field of treatment and prevention of cardiopathologies in children with cancer in practice.

Conclusions

Thus, it can be concluded that the formation of an interdisciplinary approach in the field of prevention and treatment of cardiopathologies in children with cancer will eliminate gaps in the knowledge of specialists and improve the results of treatment of children with cancer. An early detection of cardiovascular diseases and a preventive initiation of drug treatment improves the quality of life as well as increases the longterm survival rates of such children.

Statement on ethical issues

Research involving people and/or animals is in full compliance with current national and international ethical standards.

Conflict of interest

None declared.

Author contributions

The authors read the ICMJE criteria for authorship and approved the final manuscript.