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Oncologists vary widely in treating DLBCL with cardiomyopathy, often diverging from guidelines due to limited evidence on cardioprotective strategies.

Oncology providers vary widely and diverge from guidelines in their preferred treatments of adults with diffuse large B-cell lymphoma (DLBCL) and pre-existing cardiomyopathy, according to the results of a nine-country survey demonstrate.

“In this international survey of 50 oncology providers who treat adults with lymphoma, there was substantial variability in preferred treatment regimens in patients with preexisting cardiomyopathy and DLBCL with lack of evidence cited as the main reason for not using cardioprotective strategies such as liposomal doxorubicin, dexrazoxane, and continuous doxorubicin infusion,” researchers wrote in Leukemia & Lymphoma.

“In addition, despite practice guidelines recommending post-anthracycline echocar­diograms in adults receiving more than 250 mg/m2 of doxorubicin, only a minority of providers report obtain­ing routine screening echocardiograms after comple­tion of anthracycline-based chemotherapy regimen with a cumulative dose of 300 mg/m2,” they added.

Jenica N. Upshaw, MD, and colleagues developed an anonymous electronic survey they emailed to 12 academic medical systems, three US lymphoma cooperative groups, and two community hospitals, and distributed at one international lymphoma meeting. Overall, 70% of the 50 hematology-oncology providers caring for adult patients with lymphoma practiced in the US, and 94% of respondents practiced in academic settings.

The survey presented two patient vignettes and analyzed the respondents’ preferred treatment choices for patients with cardiac risk, use of cardioprotective strategies, post-treatment surveillance, and willingness to participate in clinical trials.

Multiple Strategies for DLBCL With Mild Cardiomyopathy

The first vignette presented “a 67-year-old patient with newly diagnosed Stage III DLBCL with known coronary artery disease and a left ventricular ejection fraction of 40-45% on screening echocardio­gram. She has no cardiopulmonary symptoms, ECOG PS 0, and no other comorbidities.”

Clinicians were asked how they would treat this patient.

• 83% of respondents said they would refer the patients to a cardiologist or cardio-oncologist.
• 30% recommended a non-anthracycline regimen, most commonly R-CEOP (rituximab, cyclophosphamide, etoposide, Oncovin (brand name for vincristine, and prednisone).
• 26% selected R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin (another name for doxorubicin), vincristine, and prednisone) with liposomal doxorubicin instead of doxorubicin
• 22% chose R-CHOP without modification.
• 12% selected R-CHOP with continuous doxorubicin infusion instead of bolus dosing.
• 6% chose R-miniCHOP (reduced-dosage version of CHOP).
• 2% opted for R-CHOP with dexrazoxane.

 Reasons for not choosing specific regimens included lack of evidence, toxicity concerns, costs, and insurance issues.

Respondents were also asked about their real-world use of cardioprotective strategies over the past 5 years.

Post-Treatment Cardiac Monitoring Strategies

The survey also explored follow-up practices for asymptomatic survivors.

The second vignette presented “a 42-year-old male is treated with ABVD [Adriamycin (brand name of doxorubicin), bleomycin, vinblastine, and dacarbazine] for six cycles (doxorubicin cumulative dose 300 mg/m2) for Stage III HL and is in remission after treatment.”

The patient has no comorbidities and no symptoms during routine follow-up. His pretreatment echocardiogram was normal with an LVEF of 55%, a global longitudinal strain of -19%, and no valvu­lar disease.

 44% of respondents would order an echocardiogram only if heart failure signs or symptoms developed.

• 32% would routinely order a post-treatment echocardiogram.
• 14% would selectively screen patients after anthracycline, but not in this case.
• 10% would monitor cardiac biomarkers and only obtain an echocardiogram if biomarkers are abnormal or concerning symptoms are present.

Mixed Views on Clinical Trial Participation

Despite variability in care, most providers expressed support for randomized trials.

• 78% of respondents would consider enrolling the patient in a trial of R-CHOP with liposo­mal doxorubicin instead of doxorubicin versus R-CHOP.
• 70% would consider enrolling the patient in a randomized trial of R-CHOP + dexrazoxane versus R-CHOP alone.

 More Research Needed

 Dr. Upshaw and colleagues noted that the findings highlight the limited data available on how best to treat lymphoma in patients with preexisting cardiovascular disease.

They acknowledged several limitations to the study that preclude the generalizability of its results to other practice settings. For example, most respondents practiced in academic medical centers with cardio-oncology services, most participants were from the US, and the survey did not estimate the response rate.

“These findings support [the] development of a prospective trial of cardio­protective strategies for DLBCL patients with preexist­ing cardiomyopathy or symptomatic HF,” the researchers wrote.