TAVR may be beneficial in cancer

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January 18, 2019

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Uri Landes

Uri Landes

Cancer patients treated with transcatheter aortic valve replacement for severe aortic stenosis appear to do just as well in the short term as patients without cancer, but have a higher mortality rate 1 year after treatment, according to a study.

However, Uri Landes, MD, of the Department of Cardiology at Rabin Medical Center in Israel, said the findings, published recently in gepubliceerd JACC: Cardiovascular Interventions, should not exclude TAVR in all cancer patients.

β€œOn the one hand, 85% of patients survived 1 year after TAVR. On the other hand, about half of the deaths were cancer-related. One could argue that 50% cancer mortality is a lot and should discourage us from getting TAVR in these patients. I believe we prefer to look at the glass half full – half of 15% means that only 7.5% of patients died of cancer and 92.5% did not,” he wrote in an email to Cardiology Today’s intervention.

Increased mortality after TAVR

In the past, TAVR studies have excluded patients with limited life expectancy due to non-cardiac conditions, such as cancer. However, with advances in medicine, the appropriate patient population for TAVR may expand, Landes noted.

β€œAs cancer therapy improves, some patients with active cancer, including advanced metastatic disease, have a good prognosis (oncologically speaking) and may be even more at risk from their severe aortic stenosis if left untreated. We had the opportunity to see several such patients in our center, although there was no data to support such action. We also encountered some asymptomatic patients with aortic stenosis in whom TAVR was indicated before cancer-related surgery or cardiotoxic anti-cancer therapy, and which may have helped them through getting past their anticancer therapy. Ultimately, we were eager to collect data on such patients to better understand their prognosis,” he said.

Landes and colleagues analyzed information from the TOP-AS registry, which collects data on patients undergoing TAVR while having all types of active malignancy, excluding non-melanoma skin cancer. They included 222 patients with cancer from 18 TAVR centers compared to 2,522 patients without cancer from five participating centers.

The researchers found no significant differences in in-hospital and 30-day deaths, cerebrovascular events, bleeding, vascular complications, need for a pacemaker, or acute kidney injury between patients with and those without cancer.

However, in patients with cancer versus patients without cancer, mortality was higher (14.9% vs. 9%; p < 0.001) and survival was lower at 1 year (HR = 2.37; 95% CI 1.74-3.23). Compared to patients without cancer, the risk of mortality was higher in patients with stage 3 to 4 cancer at the time of TAVR (HR = 3.21; 95% CI, 2.35-4.35) but not in patients with stage 1 to 2 cancer (HR = 1.31; 95% CI, 0.96-1.78).

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Of the cancer patients who died, three quarters of deaths were not due to CV causes and half were due to cancer. Of those who survived 1 year after TAVR, 29% had cancer progression, 9% had regressed, 21% were in remission, and 14% were considered cured of their oncological disease.

In addition, half of the cancer patients were NYHA functional class I both 1 month and 1 year after TAVR.

The mean age of the cancer patients was 78.8 years. They had a score of 4.9% from the Society of Thoracic Surgeons and 62% were male. The most common cancers were gastrointestinal (22%), prostate (16%), breast (15%), hematologic (15%), and lung (11%). Half had stage 3 to 4 cancer, 31% had metastasis, 29% received antineoplastic therapy and 26% had an indication for downstream cancer-related surgery.

Importance of the heart team

In an accompanying editorial Niklas Schofer, MD, of the Department of General and Interventional Cardiology at the University Heart Center Hamburg in Germany, noted that this study, along with others, shows that the number of cancer patients undergoing TAVR is increasing, highlighting the importance of a multidisciplinary approach to treating these cancers. patients .

“The current study provides evidence that it is critical to involve specialist oncologists in the cardiac team’s decision before TAVR to accurately determine the stage of malignancy and estimated life expectancy,” he wrote, adding that symptoms of severe aortic stenosis often overlap with those of neoplastic disease.

Only patients with truly symptomatic severe aortic stenosis, Schofer noted, are eligible for TAVR.

He also emphasized the lower STS score, despite poorer outcomes, seen in patients with cancer versus those without cancer in the study.

“This indicates that attributable cancer risk is not reflected in currently available surgical risk scores,” Schofer wrote. “Applying additional risk scores to cancer patients, for example assessment of vulnerability using the ‘Katz index’ or the ‘Kanofski performance status’, could improve risk assessment in this patient population.”

The study was also not without its limitations, Schofer said. The inclusion of a wide variety of cancer types and grades of malignancy and the lack of data on quality of life after TAVR, comparison between TAVR and optimal medical therapy and a cost-effectiveness analysis leave more questions unanswered.

Nevertheless, TAVR may be appropriate for patients with early-stage cancer, Schofer wrote.

Landes also listed areas the researchers would like to see further explored.

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“Our study may indicate that although TAVR in cancer patients is associated with worse outcomes compared to cancer-free patients, it is still associated with a relatively good prognosis,” he said. β€œWe saw that cancer stage is extremely important. I think further research should focus on evaluating TAVR vs. palliative care for cancer patients with severe aortic stenosis, primarily and specifically in patients with stage 3 to 4 cancer where the cost-effective balance is more vague.”

Overall, the study underscores the importance of the heart team in decision-making, Landes said.

β€œTreating severe aortic stenosis with TAVR in oncology patients appears to be effective and safe in the short term, but has a worse one-year prognosis. In this cohort, mortality is largely due to cancer, yet 85% of patients are alive at 1 year, and importantly, a third of them are either in remission or cured of their oncological disease by then. That basically means that the heart team has to make individual decisions. It is essential that an oncologist be integrated into the heart team when discussing the optimal treatment strategy in such cases,” he said. Cardiology Today’s intervention. – by Melissa Foster

For more information:

Uri Landes, MD, can be reached at uri.landes@gmail.com.

disclosureso: Landes does not report any relevant financial disclosures. See the study for all relevant financial disclosures from other authors. Schofer reports that he has received travel reimbursement from Boston Scientific, Edwards Lifesciences and St. Jude Medical, and that he has received honoraria from Boston Scientific.

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