Many patients with severe aortic stenosis and active cancer appear to benefit from transcatheter aortic-valve replacement (TAVR), with mortality rates similar to those of patients without cancer, according to a systematic review and meta-analysis. "Cancer patients should not be automatically excluded from TAVR," Dr. Ahmed Bendary of Benha University Faculty Of Medicine, in Benha, Egypt, told Reuters Health by email. "Discussion with oncologists could help to refine the risk-assessment process in order to exclude those patients with cancer in whom TAVR would be really futile." TAVR provides an alternative to open surgery, which might not be offered to cancer patients because of concerns over a higher risk of postoperative complications and the perioperative withholding of cancer therapeutics. Patients with cancer were largely excluded from pivotal TAVR trials, however, so there is little evidence to guide clinical decision-making. Dr. Bendary's team sought to improve clinical decisions by evaluating the outcomes of TAVR in patients with or without active cancer in their systematic review and meta-analysis of three studies with a total of 5,162 patients (368 with active cancer). Overall, 30-day all-cause mortality did not differ significantly between patients with and without active cancer. But all-cause mortality at one-year follow-up was 71% higher among patients with active cancer than among those without cancer, the researchers report in Open Heart. The findings differed by cancer stage. Rates of all-cause mortality at both 30 days and one year were similar among patients without cancer and those with limited cancer stages. In contrast, patients with advanced cancer stages had similar all-cause mortality at 30 days, but significantly higher rates of all-cause mortality at one year. All-cause mortality at one year was 2.33-fold higher in patients with advanced cancer than in patients with limited cancer. The rates of device success did not differ significantly between the patient groups, and there were no significant differences in 30-day rates of bleeding, stroke, or acute kidney injury. Cancer patients had a 29% higher risk of requiring a postprocedural pacemaker (P=0.01), however. "Treatment decisions should remain largely individualized among this subset of complex patients, considering that active cancer is not represented in preoperative risk scores and that cancer stage might matter," the authors conclude. "Remember, it is bitter to imagine that cancer patients might succumb to their valvular problem rather than cancer itself!" Dr. Bendary said. "What's more, correcting severe aortic stenosis could ease their access to advanced cancer therapies, e.g., surgery." "All studies included in this meta-analysis are observational," he noted. "Therefore, despite being the best attainable estimate to date, any conclusions drawn should be cautiously interpreted. Of course, randomized trials comparing TAVR to optimal medical treatment in patients with cancer and severe aortic stenosis are essential to definitively solve this clinical conundrum; however, these types of studies are lacking, and it remains doubtful whether such trials will (be done) in light of some prohibitive ethical issues." Dr. Ran Kornowski of Rabin Medical Center, in Petach Tikva, Israel, who recently reported TAVR outcomes in oncology patients with severe aortic stenosis, told Reuters Health by email, "There is a new hope for patients with cancer and aortic stenosis, and TAVR seems to be the preferred therapeutic technique for suitable patients in need of intervention." "If the oncology patient is too sick and/or too frail due to advanced cancer and the predicted prognosis is less than one year, most probably TAVR is not advisable," he said. "In this case, conservative management or balloon aortic valvuloplasty should be considered. Nonetheless, if aortic stenosis dominates the clinical scenario, thus TAVR should probably be considered." "It is essential to adopt a multidisciplinary cardio-oncology team approach geared towards precise diagnosis and therapeutic decision for the benefit of patients who suffer from the double clinical jeopardy syndrome," said Dr. Kornowski, who was not involved in the new review. He added, "Although the data are quite limited in this field of investigation, the findings seem to be robust, and more research is needed in order to optimize the decision-making process and the treatment pathway for patients with cancer and severe symptomatic aortic stenosis." —Will Boggs MD Source
