Incidental Cancer on a Pre-TAVI Workup Tied to Poorer Outcomes

When incidental malignancy is found on CT imaging performed as part of a TAVI workup, patients fare worse after their valve procedures, a registry study shows.

Those who had cancer detected were roughly two to three times more likely to die from any cause at both 1 and 5 years post-TAVI, according to a research letter published online in the American Heart Journal.

The study raises questions about whether operators should proceed with TAVI in this group, say investigators.

“We say if you have survival prognosis of less than 1 year, TAVI is probably futile,” senior author Thomas Pilgrim, MD (Inselspital, Bern University Hospital, Switzerland), told TCTMD, noting that in this cohort, more than 30% of patients with incident cancer had died by that time point.

But Pilgrim believes that people suffering from severe aortic stenosis (AS) symptoms should still be considered for transcatheter valve replacement.

“Even if you have a life expectancy of 6 months, if you are severely symptomatic, probably it’s worth the intervention just to replace the valve so that the last 6 months are more comfortable,” Pilgrim said. And if symptomatic relief isn’t enough to justify the procedure, he noted that many patients will not be eligible to undergo potentially life-prolonging cancer surgery if they have severe aortic stenosis.

“I think in most of the patients, and particularly if you’re now moving towards younger patients, if you have an incidental malignancy, it doesn’t mean that you defer TAVI, but it means that you do the TAVI and then you take care of the incidental malignancy,” Pilgrim said.

Cezar Iliescu, MD (University of Texas MD Anderson Cancer Center, Houston), agreed, saying that between the time of the pre-TAVI workup and the procedure, these patients should be seen by a specialist—an oncologist, a cardio-oncologist, or an internal medicine physician with expertise in the suspected cancer—to explore treatment options. Even if a brief delay is necessary, TAVI should be done.

“The valve should be fixed before you do anything else for the cancer therapy,” commented Iliescu, who is president and founder of the Interventional Onco-Cardiology Society.

Incidental Findings Common

Multiple studies have shown that incidental findings are frequently found on pre-TAVI imaging, which is used to assess anatomic feasibility and suitability for the procedure, but there are fewer data regarding the clinical impact of those findings, particularly over the long term, Pilgrim said.

For the current study, with lead authors Caglayan Demirel, MD, and Daijiro Tomii, MD (Inselspital, Bern University Hospital), the focus was on incidental malignancy, which has been shown to be more influential in terms of prognosis than other incidental findings. The investigators examined prospectively collected data on 579 patients who underwent TAVI in 2015 and 2016 and were included in the Bern TAVI registry.

These days the outcomes are actually really very, very good, and a lot of malignancies and a lot of treatments are really tolerated outstandingly well by the patients. Cezar Iliescu

Pre-TAVI imaging uncovered incidental findings of any type in 63.5% of patients, including those suspicious for malignancy in 20.2%; cancer was confirmed in 4.5%. That one in five patients had suspected cancer is a concern because of both the resources needed to further investigate the findings and the anxiety caused, Pilgrim said.

Compared with patients without incidental cancer, those with a confirmed malignancy were similar in age (81 years), included roughly equal proportions of women and men, and had the same burden of cardiovascular comorbidities.

Of note, most patients with cancer (61%) declined treatment for it, with the remainder receiving chemotherapy, radiation therapy, or tumor surgery. Pilgrim pointed to the older patient population as a reason most chose not to address the cancer—which was asymptomatic—and instead prioritized lessening the symptoms of valve disease.

Through 5 years, 18 of the 26 patients who had incidental malignancy detected on the pre-TAVI workup died—with 12 of the deaths related to cancer, five to cardiovascular disease, and one to an unknown cause.

The rate of all-cause death was significantly higher among patients with versus without incidental cancer at both 1 year (31.9% vs 11.4%; HR 2.87; 95% CI 1.37-6.00) and 5 years (72.0% vs 43.4%; HR 2.48; 95% CI 1.54-4.02). Mean survival time was about 16 months shorter in patients with malignancy.

How to Handle the Situation?

These findings, the authors note, are consistent with a prior study of patients with active cancer who were treated with TAVI, which showed that those with versus without cancer had a higher 1-year mortality rate.

That’s not surprising, said Iliescu, because in this scenario, it’s the cancer that’s driving outcomes after the aortic valve has been fixed. And that’s why it’s so concerning that most of the patients with incidental cancer in this study declined treatment, he added, suggesting that this could be related to outdated notions about cancer therapy.

Treatments have gotten much better over the past decade or two, and more patients are surviving, he said. At MD Anderson, for example, 60% to 70% of patients are survivors. “I think it’s part of the education that has to be done so the patients do not throw in the towel that fast,” Iliescu said. “These days the outcomes are actually really very, very good, and a lot of malignancies and a lot of treatments are really tolerated outstandingly well by the patients.”

Importantly, the vast majority of patients with cancer and severe aortic stenosis should be able to undergo treatment for both conditions, regardless of whether the cancer or the valve disease is the incidental finding, Iliescu said. He acknowledged that canceling TAVI in a patient with a serious enough cancer detected on the preprocedural workup “is a legitimate scenario,” albeit one that applies to only a small proportion of patients.