Remote monitoring of cardiac function in childhood cancer survivors

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Abstract Cardiovascular complications are a leading cause of morbidity and mortality in survivors of childhood cancer. These survivors have a greater than four-fold risk of developing heart failure (HF) when compared to age- matched controls, and there is a strong dose-dependent association between anthracycline exposure and the risk of heart failure. Outcome following HF is poor, emphasizing the importance of early detection of cardiac dysfunction (e.g. abnormal left ventricular ejection fraction [EF]) with cardiac imaging and initiation of pharmacologic therapy prior to the development of clinically overt disease. Unfortunately, the period in time when survivors are at the greatest risk of HF also corresponds to the time when they are least engaged in risk- based survivorship care. New paradigms in clinical care and chronic disease management are needed for these survivors. Recent advances in mobile technology have facilitated the development of a new sector of mobile healthcare diagnostics (mHealth) that has the potential to combine the utility of standard of care cardiac monitoring by echocardiography with the accuracy of more advanced diagnostic imaging (cardiac magnetic resonance [CMR]). However, neither the reproducibility nor the cost-effectiveness of this mHealth technology for prospective clinic- or home-based cardiac monitoring in cancer survivors is known. To address these knowledge gaps, we will enroll 200 long-term childhood cancer survivors who previously underwent a one-time assessment of cardiac EF by echocardiography, CMR, and a handheld Bluetooth-enabled device (Vivio) to validate the accuracy of Vivio EF in the clinic setting, and to determine its reproducibility at home (Aim 1). We will also leverage the expertise of our investigative team to determine the cost-effectiveness of Vivio-based screening using Markov modeling (Aim 2). This study will: 1) provide an important follow-up timepoint that will confirm the accuracy of EF, as measured using Vivio, in anthracycline-exposed survivors; 2) demonstrate the reproducibility of self-administered home-based measures of cardiac function in survivors who may no longer be able to maintain survivorship-focused care at the cancer center; and 3) establish whether Vivio-based screening is a cost-effective alternative to current standard of care cardiac imaging approaches. Information obtained from the current study can be used to develop strategies that facilitate screening and management of cardiac dysfunction during cancer treatment, or after completion of therapy in other at-risk cancer populations (e.g. adult survivors of lymphoma treated with known cardiotoxic [anthracyclines, chest radiation] therapies or newer immunotherapies, adult survivors of breast cancer treated with anthracyclines and/or trastuzumab) who face similar challenges in long-term follow-up. The growing population of long-term cancer survivors at risk for cardiovascular disease makes development of screening and prevention strategies imperative, to ensure that these survivors live long and healthy lives well after completion of their cancer treatment.