Prevalent Heart Failure And Cardioprotective Medication Use In Older Individuals With Lymphoma: A SEER-Medicare Analysis

Abstract

Background Older patients with lymphoma are at increased risk for cardiotoxicity with anthracycline-based cancer treatment. Dexrazoxane and liposomal anthracyclines may reduce the risk of heart failure (HF); although, neither clinical practice guidelines nor the FDA endorse the use of these cardioprotective medications in this population due to insufficient evidence. No studies to date have explored the prevalence of “off label” use of these cardioprotective strategies in clinical practice. Methods The Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked database was used to identify individuals with newly diagnosed Diffuse Large B Cell Lymphoma (DLBCL) and Hodgkin's Lymphoma (HL) diagnosed from 2000-2015 who had one year of Medicare Part A and B coverage in the year prior to diagnosis. Exclusion criteria included age <65 years, HMO membership, and lymphoma diagnosed on death certificate. Prevalent and incident HF/cardiomyopathy were defined using International Classification of Diseases codes using a validated algorithm (Go, JAMA 2006). HCPCS codes were used to identify doxorubicin (C9415, J9000), liposomal doxorubicin (J9001, Q2048, Q2049, Q2050) and dexrazoxane (J1190). Results Among newly diagnosed individuals with DLBCL (n=30,728) and HL (n=3,348), HF in the year prior to diagnosis was present in 14% of the population. Anthracycline-based chemotherapy was used in 34% of DLBCL cases and 52% of HL cases. Radiation was used in 19% of HL and DLBCL cases. In those free from HF at the time of lymphoma diagnosis, incident HF was very common, occurring in 28% of those treated for HL and 26% of those with DLBCL over a median of 2.4 years and 2.7 years, respectively. Among those treated with anthracyclines, liposomal formulations were used in 2.1% of those with DLBCL and 1.2% of those with HL; while dexrazoxane was used in 0.7% of those with DLBCL and 0.8% of those with HL. Conclusions Despite a high prevalence of HF at the time of lymphoma diagnosis and very high risk of incident HF, cardioprotective medications were rarely used. Randomized trials of cardioprotective strategies are needed to improve cancer and cardiovascular outcomes in this high-risk patient population. Older patients with lymphoma are at increased risk for cardiotoxicity with anthracycline-based cancer treatment. Dexrazoxane and liposomal anthracyclines may reduce the risk of heart failure (HF); although, neither clinical practice guidelines nor the FDA endorse the use of these cardioprotective medications in this population due to insufficient evidence. No studies to date have explored the prevalence of “off label” use of these cardioprotective strategies in clinical practice. The Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked database was used to identify individuals with newly diagnosed Diffuse Large B Cell Lymphoma (DLBCL) and Hodgkin's Lymphoma (HL) diagnosed from 2000-2015 who had one year of Medicare Part A and B coverage in the year prior to diagnosis. Exclusion criteria included age <65 years, HMO membership, and lymphoma diagnosed on death certificate. Prevalent and incident HF/cardiomyopathy were defined using International Classification of Diseases codes using a validated algorithm (Go, JAMA 2006). HCPCS codes were used to identify doxorubicin (C9415, J9000), liposomal doxorubicin (J9001, Q2048, Q2049, Q2050) and dexrazoxane (J1190). Among newly diagnosed individuals with DLBCL (n=30,728) and HL (n=3,348), HF in the year prior to diagnosis was present in 14% of the population. Anthracycline-based chemotherapy was used in 34% of DLBCL cases and 52% of HL cases. Radiation was used in 19% of HL and DLBCL cases. In those free from HF at the time of lymphoma diagnosis, incident HF was very common, occurring in 28% of those treated for HL and 26% of those with DLBCL over a median of 2.4 years and 2.7 years, respectively. Among those treated with anthracyclines, liposomal formulations were used in 2.1% of those with DLBCL and 1.2% of those with HL; while dexrazoxane was used in 0.7% of those with DLBCL and 0.8% of those with HL. Despite a high prevalence of HF at the time of lymphoma diagnosis and very high risk of incident HF, cardioprotective medications were rarely used. Randomized trials of cardioprotective strategies are needed to improve cancer and cardiovascular outcomes in this high-risk patient population.