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Take a look at a selection of our recent media coverage:
3rd February 2025
Using procalcitonin (PCT) levels to guide intravenous antibiotic use in children hospitalised with bacterial infections does not shorten the duration of therapy compared with usual care, a large UK study finds.
Previous research had suggested that PCT – a rapid response biomarker for bacterial infection – could guide antibiotic discontinuation, but the test was not routinely used in the NHS, the study authors wrote in The Lancet Child & Adolescent Health.
In a multicentre trial at 15 hospitals in England and Wales, researchers assessed whether a PCT-guided algorithm would safely reduce the duration of antibiotic therapy in children hospitalised with confirmed or suspected bacterial infections compared with usual care, which commonly used C-reactive protein as a biomarker.
Children aged 72 hours to 18 years who were hospitalised and being treated with intravenous antibiotics for more than 48 hours were eligible for the trial.
Between 11 June 2018 and 12 October 2022, a total of 15,282 children were screened for eligibility, with 1,949 randomly assigned (1:1) to receive either current clinical management alone (usual care group) or clinical management with the addition of a PCT-guided algorithm (PCT group).
In the PCT group, plasma PCT levels were tested at baseline and every one to three days during intravenous antibiotic treatment.
Assay results were fed into an algorithm which provided guidance on antibiotic management; however, clinicians could decide to over-rule the algorithm.
The study found the addition of a PCT-guided algorithm was non-inferior in terms of safety but did not reduce the duration of intravenous antibiotic use compared with usual care.
In addition, a cost-effectiveness analysis showed that PCT-guided antibiotic management was more costly than usual care.
The median intravenous antibiotic duration was 96 hours in the PCT group and 99.7 hours in the usual care group (hazard ratio 0.96 [95% CI 0.87–1.05]), data showed.
Of the 917 participants in the PCT group, 78 (9%) had at least one event covered by the composite safety outcome measure compared with 85 (9%) of 904 participants in the usual care group (estimated adjusted risk difference –0.81% [95% CI upper bound 1.11]).
Among the study limitations, the researchers noted low adherence to the PTC-guided algorithm (36% at first clinical review and 54% at any clinical review).
In addition, the four hospitals who recruited the most participants had already implemented antimicrobial stewardship programmes.
Concluding, the authors recommended PCT-guided algorithms should be tested in subgroups of paediatric patients to establish whether they can reduce the duration of intravenous antibiotic treatment among patients with specific clinical characteristics.
Study chief investigator Professor Enitan Carrol, professor of paediatric infection at the University of Liverpool, UK, noted the study was a pragmatic trial in which clinicians did not have to adhere to the diagnostic algorithms.
‘Adherence to the algorithm was low in our study, and there were challenges in integrating the test into routine clinical workflows,’ he said.
‘The study highlights the importance of including behaviour change and implementation frameworks into pragmatic trial designs.’
The research, known as the ‘Biomarker-guided duration of Antibiotic Treatment in Children Hospitalised with confirmed or suspected bacterial infection’ (BATCH) trial, was led by the University of Liverpool and conducted in collaboration with Cardiff University’s Centre of Clinical Trials Research, with funding from the National Institute for Health and Care Research (NIHR).
It followed a National Institute for Health and Care Excellence recommendation for further studies to assess the effectiveness of adding PCT algorithms to guide antibiotic treatment in hospitalised adults and children with suspected or confirmed serious bacterial infections.
Late last year, a large NIHR-funded and commissioned trial in adults found PCT-monitoring could significantly reduce antibiotic overuse in sepsis.
Professor Martin Röcken talks to Helen Quinn about the current challenges and opportunities in dermatology treatments, particularly when it comes to immunotherapy for skin cancers, the importance of multidisciplinary working to optimise patient care, and his hopes for the future of the field.
Professor Martin Röcken is established as the chairman of a large dermatology department at the University Hospital Tübingen in Germany and head of the Röcken Laboratory at the same University. He has worked in this department for the past 22 years, overseeing some of the most dramatic developments in dermatology and playing a pivotal role in establishing immune-based therapies in inflammatory skin diseases and oncology.
Having recently concluded his tenure as president of the European Academy of Dermatology and Venereology and as clinical chair, Professor Röcken is committed to advancing knowledge, translating research into treatment advances and improving patient care.
‘There’s a large spectrum of very exciting areas in dermatology. My goal was and is to jointly advance both clinics and research,’ he explains.
Nowhere is this translational research more apparent than in the pioneering oncology work undertaken in the field of dermatology by the Röcken laboratory, especially in developing immune-based cancer therapies.
Professor Röcken explains: ‘The development of cancer immune therapies has mainly come from dermatology. Dermatology has a very strong oncology group that started with the first treatment trials. We pushed it, really, from the beginning.’
The idea of immunotherapy – driving the immune system to be stronger against cancers – evolved around 30 years ago, but there were no sustainable results from studies at the time. The breakthrough occurred when researchers realised that working to get a stronger, more sustained immune response would not work against cancer because the cancer was silencing the body’s immune response to protect itself.
The trials that followed around a decade ago, showed that if, instead of boosting immunity, the immune response was silenced, then a sustained autoimmunity could develop against melanoma metastases, which until then was a tumour resistant to almost all therapies.
‘If melanomas respond to therapy, you may have a relatively quick response; you see what’s happening. As there was no therapy for metastatic melanomas, and as melanomas responded to the first immunotherapy trials, melanomas were originally used to establish immune therapies,’ he explains. ‘Both specific drug inhibiting cancer proliferation and immunotherapy were developed in dermatology over the past 15 years.’
Following the successful trials, immunotherapy was approved for use in melanoma in 2017 and shortly after for other cancer types, including lung, kidney and some types of gastrointestinal cancers.
Despite notable milestones that have transformed patient treatment, Professor Röcken says many unsolved issues remain. He describes how limitations in immunotherapy emerged earlier than expected, prompting his lab to investigate how the therapy can be used more efficiently and how best to treat patients.
Previously, when a patient had metastatic disease, clinicians would undertake surgery first and then give immunotherapy to prevent the relapse. ‘But what dermatologists realised is that it’s better to first do immunotherapy and then surgery later,’ says Professor Röcken.
For this neoadjuvant therapy approach, dermatology again took the lead, and the concept is now being tested in lung and other cancers.
Finding new ways to treat ‘very difficult cancers’ is also high on Professor Röcken’s radar. For patients who undergo transplant surgery and develop lymphomas of the skin, treatment options can often be limited since the cancer cannot be controlled by treatments which target their immune system.
Alongside the innovations in oncology, the field of dermatology has made significant advances in the treatment of inflammatory and autoimmune diseases. This includes monoclonal antibodies and novel small molecules.
A new generation of drugs that can suppress the immune system – especially antibodies that are highly specific to certain pathways or diseases – are now available to patients.
‘When I started 30 years ago, it was much less satisfactory to treat patients than today. Often when we had patients with joint psoriasis, and we couldn’t treat them sufficiently, and they were desperate. Now they come in, and we can really help them,’ states Professor Röcken.
The new drugs mean there are now more opportunities to treat diseases that were once difficult to treat.
‘We [as clinicians] are now more happy than the patients because they don’t realise anymore what the reality would be without the drug. It’s a nice position to be in, I’m happy, and they consider this normal,’ he adds.
However, Professor Röcken cautions that although these new drugs offer advantages over traditional treatment options, concerns remain about their high cost and widespread use for long-term conditions.
‘The main challenge for the future will be to have a balanced view between the classical drugs and the new drugs to see how long to use them and to know more about their [long-term] safety. Then we can go towards a really bright future for the patients,’ he says.
‘Importantly, we also have to value previous medications such as methotrexate. Some of these drugs are highly effective in terms of treatment outcomes, have very few long-term safety concerns and are not costly at all. They can really help many patients worldwide and should be the first choice to think of.”
Researchers investigating treatments for inflammatory disease found that symptoms could be reduced through the use of antibodies. These therapies were originally established in dermatology and rheumatology based on the understanding that they ‘could be used to target distinct pathways, such as the tumour necrosis factor pathway, the interferon pathway, the interleukin-23/17 pathway and the immunoglobulin E pathway’, Professor Röcken explains.
‘These pathways could be blocked with antibodies, which allowed for the treatment of a large spectrum of very different skin diseases. Now, antibodies are used not only for joints and psoriasis but also for a series of other diseases affecting internal organs, like bowel diseases or lung diseases.’
Professor Röcken hopes that new treatments will become more manageable for his patients, and novel ideas are currently being developed. For example, the antibodies currently injected into patients to treat conditions such as atopic dermatitis and asthma will eventually be developed into pills, which will be much more convenient.
Trials are ongoing, alongside the development of other solutions, such as medications that can block not only the soluble mediators that cause the disease but also the signalling. This will give patients new drugs that are as efficient as the antibodies.
One of the ‘hottest’ new treatment advances for dermatology patients, according to Professor Röcken, lie in the exploration of gene therapies. This area is beginning to offer hope for dermatological patients with rare but severe genetic conditions.
Topical gene therapy is being trialled as an effective treatment for a rare disease in which patients lack the molecule that anchors the upper skin to the lower skin.
‘A cream which contains missing genes goes into the wounded skin and starts to educate it to make the correct molecules. It’s very early, but this shows that you can make gene replacement. One can think of topical gene therapy as replacing genes missing in the skin,’ Professor Röcken explains.
‘It’s fantastic – that’s one of the hottest newest advances. It’s not yet where we want to be, but it shows it works.’
The transformative developments in dermatology over recent years would not be possible without input from other areas of medicine. Professor Röcken stresses the importance of multidisciplinary working across all strands of dermatology. ‘We have six to eight hundred new melanoma patients each year, so we have weekly interdisciplinary meetings with colleagues from radiology, internal medicine and surgery,’ he says.
In addition, his hospital department is very closely linked to paediatrics, internal medicine and neurology, facilitating better patient outcomes and exchanging information on the latest developments in order to treat more complex patients through a combined approach.
This collaboration will continue to be required as Professor Röcken focuses his future research on immunogenetics, particularly how genetic factors influence responses to immune-based cancer treatments.
‘What I’m doing now is going beyond to see why some cancers fail despite the best treatment. What are the reasons? Is it the cancer? Is it the patient’s response? So, we go into basic questions to understand where the problems are coming from. And it’s quite promising,’ he says.
There is undoubtedly much more to come from the Röcken laboratory.
31st January 2025
Speaking at Hospital Healthcare Europe’s Clinical Excellence in Cardiovascular Care event, Dr Rebecca Dobson discussed the acute need to assess cardiovascular risk in cancer care, understanding cardiotoxicity and the importance of multidisciplinary team coordination in cardio-oncology.
Following on from her previous Clinical Excellence session in which she discussed the need and demand for cardio-oncology services, Dr Rebecca Dobson, consultant cardiologist specialising in imaging and cardio-oncology at Liverpool Heart and Chest Hospital, turned her attention to considerations such as baseline assessment, cardiovascular risk factors and the impact of systemic anti-cancer therapy on the cardiovascular system – even years down the line.
Dr Dobson also championed collaborative care between cardiology, oncology, radiology and other fields to ensure patients can continue their cancer therapy alongside cardio-protective therapies to optimise their short- and long-term outcomes.
Trends change, and cancer is becoming more common, but happily cancer survival has also doubled in the UK in the last 40-50 years. It’s really important that we, as cardiologists and cardiology teams, don’t shy away from this group of patients, because there’s a lot we can do from a cardiovascular perspective to help them live long, healthy lives after they’ve had cancer.
The authors of a recent paper in the European Heart Journal looked at all patients with cancer and stratified them according to cancer mortality rate and cardiovascular disease mortality rate.
In one group, the patients sadly have very high cancer mortality rates (70-90%) and, as a cardiologist, there’s very little I can do with that cohort of patients to change the natural trajectory of that disease. The impact from a cardio-oncologist perspective is relatively low.
The second group of patients have a slightly lower cancer mortality rate (40-60%) and an increasing cardiovascular disease mortality rate (10-20%), and there’s more we can do in terms of trying to reduce long-term effects of systemic anti-cancer therapies and reducing the risk of cardiotoxicity to avoid cardiovascular complications.
In the third group, these patients are as likely to die from cardiovascular disease as they are from their cancer – both at 20-30%. It’s really important that we don’t cure these patients’ cancer and then leave them alone. We really need to optimise the cardiac care of these patients to consider them as a whole, not just as a cancer patient.
As a consequence of increasing cancer rates and survival, more patients are being exposed to potentially cardiotoxic therapies, and more people with pre-existing cardiovascular disease – who 30 years ago would have died of their cancer – are now surviving. That’s where the subspecialty of cardio-oncology has come from.
We specifically see three different groups of patients. Firstly, we see patients at the beginning of their cancer journey to risk-stratify them. That could be a patient with any cardiovascular disease who then receives a cancer diagnosis and needs to be risk-stratified and optimised from a cardiovascular perspective. Importantly, there needs to be a discussion with the oncology team about that patient’s cancer therapy to ensure it won’t destabilise their existing cardiovascular disease.
As patients go through their cancer journey, we screen and monitor them to detect cardiovascular injury at earliest possible stage so we can get them on appropriate cardio-protective therapies and reduce the interruptions to systemic anti-cancer therapy.
This has been a big change over the last 10 or 20 years. Historically, if you had cancer and then you developed potential cardiotoxicity, it was a binary decision. Sadly, for these patients, cancer therapies were generally discontinued, whereas now we try to continue cancer therapy wherever possible.
The last group of patients we see within the cardio-oncology service is screening and monitoring patients who are cured of their cancer but are at risk of significant long-term cardiovascular late effects.
Classically, this would be patients who had a haematological malignancy or a bone cancer as children or young adults and received significant amounts of anthracycline chemotherapy. We know that puts them at risk of late-effects even 30 years later.
We don’t want these patients to be discharged and forgotten about but then present in adulthood in heart failure. So, we’ve set up a service, certainly in Liverpool, whereby every patient who has had a significant dose of anthracyclines gets put into a late effects clinic. We see them every three to five years, so they don’t fall off that cliff.
Baseline assessment is a little bit contentious from an oncology point of view, and oncology teams have a lot to do with their patients when they first get their cancer diagnosis. To then ask them to also risk-stratify patients from cardiovascular perspective is challenging.
As a cardio-oncologist, I see my role as facilitating this baseline assessment and I work with the region’s oncology teams to do this.
It helps us consider what changes may be required to systemic anti-cancer therapy and enables us to potentially detect undiagnosed cardiovascular problems at baseline.
We are performing increasingly more investigations on patients receiving chemotherapy and radiotherapy. It can be difficult to interpret these investigations without a baseline for comparison otherwise we won’t know if cancer therapy has caused an issue or whether there was pre-existing disease. It also enables us to reduce the risk of cardiotoxicity as patients move through treatment.
I recommend that you download the European Society of Cardiology’s guidelines on cardio-oncology because it gives a helpful overview. It’s a large document but there’s lots of useful information in there.
When I talk to oncologists, they’ll often ask, ‘how do we assess cardiovascular risk, what is it we need to do?’ The first thing to say is that not every patient needs every test. I’m a real believer in that there’s no point doing a test unless you know what you’ll do with an abnormal result. That’s particularly challenging for oncology teams who aren’t used to dealing with echoes, troponins, NT-proBNPs, cardiac MRI scans or sometimes even ECGs.
It’s really important to tailor the approach to the patient depending on their comorbidities and what systemic anti-cancer therapy is proposed. Things like age, sex, demographics, past medical history, lifestyle factors like smoking or being overweight, a family history – if alarm bells are ringing as the history is being taken and the examination is happening, then you might think that the patient needs to go on to have further complementary tests.
It’s really important when we’re setting up these services that cardiology teams work collaboratively with oncology teams to make sure pathways are in place to help us work out what we’re going to do with the abnormalities.
There’s an easy way of quantifying risk now. If you download the free ESC app, you can access risk calculators. It’s easy to fill out the yes or no questions and it gives you a risk at the end: low, medium, high and very high.
The four outcomes are very arbitrary, but the ESC cardio-oncology guidelines stipulate that this is the approximate risk we should be discussing with patients – high-risk conversations will be very different to low-risk ones.
If you’re low risk, you’ve got a less than 2% chance of developing cardiotoxicity, although note that it’s not zero – I always tell patients we can never say they won’t develop a cardiovascular problem. Low-risk patients should have standard monitoring, and, hopefully, as cardiologists or cardio-oncologists, we don’t need to get involved with them.
Medium-risk patients should have closer monitoring, which will differ depending on your region’s resources. We don’t see medium-risk patients here, but we often speak with oncology teams and suggest closer echo or blood pressure monitoring, whatever the issue might be.
High-risk and very high-risk patients have a substantially increased risk of cardiotoxicity. A cardio-oncologist or a cardiologist with an interest in oncology should be involved to optimise them from a cardiovascular perspective. It’s about having an open discussion with the oncologist about their proposal and the additional risk and then feeding that back to the patient.
I tell patients this is a balancing act and we’re trying to ensure the benefit of cancer treatment outweighs cardiovascular risk. There are only few circumstances where it doesn’t and the risk of killing them with chemotherapy is higher than the risk of curing them.
People have different levels of acceptable risk and different priorities, so involving them in decisions is really important. My role is to facilitate safe cancer therapy.
Whenever we thought about cancer and the heart, we used to think about Herceptin and heart failure. Certainly, we do see left ventricular systolic dysfunction associated with Herceptin, but nowhere near as frequently as we used to because of all the cardio-oncology measures that are in place.
Occasionally we see patients with dramatic cardiotoxicity that develops as they’re receiving their cancer therapy. Classically, for example, someone who is receiving paclitaxel and acutely decompensates. They might get chest pain or go into heart failure, but, actually, these patients tend to do well and it’s reversible so they recover as quickly as they deteriorated.
We see patients who have early cardiotoxicity in the days and weeks following systemic anti-cancer therapy, or we can see it months or years later. There’s a challenge there to unpick the timeline and work out what’s causing what. Certain drugs are good at causing late effects and other drugs cause acute cardiotoxicity.
I learn all the time, as cancer therapies develop, about new cardiovascular toxicities or new presentations of cardiotoxicity. It’s really important to keep an open mind when looking after patients who have cardiac issues and have received, or are receiving, systemic anti-cancer therapies and think could these two things be related.
Not only do we see a spectrum in terms of the timeline, we see a spectrum with the cardiotoxicity and the clinical presentation.
Hypertension is hugely under-recognised and under-treated in cancer patients. We know there’s a lot of overlap between risk factors for cancer and for cardiovascular disease, so it’s not surprising that many cancer patients have hypertension. If you add in that they’ve been diagnosed with cancer; they’re likely to be undergoing challenging, difficult-to-tolerate treatments; and they’re anxious, frightened, in pain, anaemic and tired – all these will raise their blood pressure.
Then you’re giving them cancer drugs, many of which can cause hypertension. We can see why 40% of patients with cancer have hypertension. But we undertreat it and we excuse it, but we should be managing it like we would with any other patient with hypertension. We should be monitoring them appropriately and getting them on antihypertensive medications.
Vascular toxicity tends to be more of an issue with the treatments we use for gastrointestinal cancers. We see destabilisation of coronary artery plaques, patients presenting with myocardial infarction, patients with coronary artery spasm. This may just be a bit of indigestion-type chest pain, and the patient may not even present to a healthcare professional but, at the other end of that spectrum, we’ve seen patients with coronary artery spasm who’ve presented with a cardiac arrest. It’s really important that these patients are taken seriously when they say they’ve got chest pain and that everyone is aware that it is a recognised vascular toxicity of the these chemotherapeutic agents.
Myocarditis is an increasing worry with patients who receive checkpoint inhibitors or immunotherapy. When I started in cardio-oncology, we only used immunotherapy for patients with melanoma or renal cell carcinoma. Now, around 75% of cancer patients are eligible for treatment with immunotherapy and that’s not just in a palliative setting, but in a neoadjuvant and adjuvant setting.
Checkpoint inhibitors have a 2% risk of causing myocarditis, and if we miss this and don’t treat it, the patient will die from the myocarditis. So, it’s really important that we consider this in patients who have received immunotherapy because they may present innocuously with fatigue, ankle swelling, breathlessness. You can see there’s a challenge there because what cancer patient doesn’t have those symptoms? But keep it in mind for these patients because the sooner you recognise it, the better the outcome for the patient.
But it’s not all about cardiac function. We need to consider blood pressure, QT interval, myocarditis and, thinking about later effects, things like ischemic heart disease.
Patients who had radiotherapy, particularly mediastinal or left-sided radiotherapy, many years ago can present years down the line with quite significant proximal coronary artery stenoses. And it never fails to amaze me how many patients forget to tell you they’ve had cancer when you’re taking their history. I think a lot of patients block it from their memory. So, particularly if a younger patient is presenting with angina-type symptoms and you think it’s a bit unusual, always ask about their cancer history specifically.
I always say to the oncology teams regionally that cardiotoxicity is a bit of a jigsaw. Certainly, understanding the patient’s clinical presentation is key, and then using that with complementary biochemical and other cardiac investigations to fit everything together.
Within cardiology teams, we’re all familiar with troponin and NTproBNP, but remember, the oncology teams are not. It’s important we help them interpret these and have pathways in place so they know what to do with abnormalities.
Imaging, obviously, is our backbone of decision making within cardio-oncology. It’s really a complimentary modality to help us put into context the clinical signs and symptoms and the biochemistry. Where possible, we should be measuring global longitudinal strain (GLS) and ejection fraction using 3D volumes in all our oncology patients.
We know 3D volumes are more reproducible and have less temporal variability. We don’t want to stop someone’s chemotherapy because we think they’ve dropped the ejection fraction when, actually, it’s just because the pictures were a bit rubbish and the 2D ejection fraction was way off. We need to make sure we’ve got accurate, reproducible echo data to help guide our decision-making.
There’s been a real shift over the last decade in trying to continue chemotherapies and radiotherapies and permitting a certain degree of cardiotoxicity. It comes back to the question of at what point does the risk outweigh the benefit?
It’s about changing your mindset from ‘should this therapy be discontinued’ to ‘how can this therapy be continued’. Because we know that if we interrupt anti-cancer therapy, it’s an independent prognostic marker for worse disease-free survival and overall survival.
For the patients with asymptomatic cardiotoxicity or mild-to-moderate cardiotoxicity, the challenge is trying to work out what to do to safely continue their cancer therapies. And that’s where the cardio-oncology service comes in with increased screening, monitoring, optimising of cardio-protective therapies.
It’s important that if we stop therapies, we consider rechallenging them. In the past, nobody would be rechallenged, but many patients will have a successful rechallenge once they’ve been optimised from a cardiovascular perspective.
That brings us back to the multidisciplinary team (MDT) and the importance of that two-way discussion with cardiology and oncology in terms of making sure that we’ve thought about everything to enable treatment to continue or be restarted.
When you’ve got a cardiologist making unilateral decisions, you’re going to run into difficulties. A pivotal part of our service is that we see patients quickly. There’s no point a patient being referred with their chemotherapy discontinued and me saying I’ll see them in six months, which is probably what a lot of cardiology outpatient waiting times are. We’ve set our service up to see patients within two weeks. If we can’t see them within that timeframe then we offer advice on cardiovascular risk to ensure treatment interruptions are minimised.
Efficient communication throughout is important. I work at Liverpool Heart and Chest Hospital, four miles from Clatterbridge Cancer Centre. That’s a different Trust with a different electronic patient record. We can’t see each other’s echocardiograms, so it’s challenging, but we’ve worked hard to improve communications between the teams.
We’re becoming more aware that it’s not just thinking about a patient’s heart or cancer but thinking holistically because these patients are complex and we want to get the decisions right.
In terms of the MDT, people dip in and out, depending on the patient and the clinical need. We have cardiologists, a cardio-oncology specialist nurse, specialised cardiac physiologists, medical and clinical oncologists, palliative care specialist nurses, pharmacists, radiologists, surgeons, anaesthetists, a dietitian.
When I started the cardio-oncology service in 2019, we ran a fortnightly clinic, but now we run three per week. We have a weekly ward round at Clatterbridge Hospital, four weekly oncology echo lists and a weekly virtual MDT where we ensure we have oncology, cardiology and radiology representation as a minimum.
Everyone’s perspective is different, and it’s really important that we all understand these to ensure that patients have the right decisions made.
Momentum is increasing, and certainly people are more aware of it now than they were 10 years ago. There are not many fully fledged cardio-oncology services, but I think more and more cardiologists and oncologists are aware of cardiotoxicity and are seeing patients within their clinics and realising they need to funnel them in a slightly different way.
We’re all aware that the NHS has no money, so trying to develop business cases and set up new services is incredibly challenging, but one of the things that I feel really strongly about is if we set up those services and risk stratify patients to optimise them at baseline, we’re hugely reducing the risk of cardiotoxicity and saving money. The drugs that we use to treat cardiotoxicity cost tens of thousands of pounds per patient, and if we can reduce the risk of that happening in the first place, prevention is definitely better than cure. I think the service will pay for itself over time, but that is very challenging.
The challenge is getting enough people interested. Everyone is busy and when you go along to a TAVI operator or a cardiothoracic surgeon and say, ‘I want to get you interested in cardio-oncology’, people run the other way. But the service does speak for itself: the more patients we see, the more we assess cardiovascular risk, the less interruptions to systemic anti-cancer therapy are happening. The oncology team certainly values the service, and they are desperate for help with this group of patients.
So, in terms of tips for setting it up, get an interested oncologist on board and start your discussions there to build a joint business case.
In terms of funding, it took me four years to get funding for a cardio-oncology specialist nurse. The only way I managed in the end was getting our local Cancer Alliance to fund a year’s salary and a private donor contributing as well. We’re all facing challenges in the current climate and it’s about looking at alternative funding sources. So, could your local hospital charity do a funding campaign for you to help with these services?
With capacity, the way we’ve set the service up means these patients are all going through dedicated cardio-oncology clinics. We make sure we save urgent slots every week, but we drowned in patients after a couple of years and I suspect that as demand goes up again, we’ll struggle. But for now, we’ve just doubled the number of clinics that we offer, and having a cardio-oncology nurse specialist has further allowed us to increase our capacity.
30th January 2025
An ultrasensitive blood test which detects even low levels of circulating tumour DNA (ctDNA) could help to improve disease stratification in early-stage lung adenocarcinoma (LUAD), a UK study suggests.
It was known that ctDNA detection could predict clinical risk in early-stage tumours, the UK research team wrote in the journal Nature Medicine. However, it was challenging to detect preoperative ctDNA in early-stage LUADs due to low levels of ctDNA in plasma – frequently below 100 ppm.
In the Cancer Research UK-funded study, scientists from University College London (UCL), the Francis Crick Institute, University College London Hospitals NHS Foundation Trust (UCLH), and the biotechnology firm Personalis, collaborated to test the company’s NeXT Personal platform.
Described as an ultrasensitive, tumour-informed liquid-biopsy platform, the researchers said NeXT Personal had been analytically validated for ultrasensitive ctDNA detection at 1-3 ppm of ctDNA with 99.9% specificity.
They used the platform to analyse preoperative ctDNA in 171 adults with early-stage lung cancer from Cancer Research UK’s TRACERx study.
It detected ctDNA preoperatively in 81% of the patients with LUAD, including 57% of those with pathological tumour-node-metastasis (pTNM) stage 1 disease.
Analysis showed people with a low level of ctDNA before surgery were less likely to relapse and also had improved overall survival rates compared with people with a high level of ctDNA.
The researchers were also able to show that patients with <80 ppm preoperative ctDNA levels had reduced overall survival compared with ctDNA-negative patients with LUAD.
‘Although prospective studies are needed to confirm the clinical utility of the assay, these data show that our approach has the potential to improve disease stratification in early-stage LUADs,’ the study authors concluded.
The data from TRACERx was analysed retrospectively, the researchers acknowledged, with future data from prospective cohorts needed to evaluate the clinical utility of the assay.
‘Although NeXT Personal is already in use as a clinical diagnostic test, it, like other tumour-informed ctDNA detection assays, is of higher complexity and requires a longer turnaround period to develop the panel and obtain a clinically actionable result, compared with non-tumour-informed approached,’ they wrote.
Study first author Dr James Black, a postdoctoral clinical fellow at the Francis Crick Institute and the Cancer Research UK Lung Cancer Centre of Excellence at UCL, said the study had shown the presence or absence of tumour DNA in the blood was strongly predictive of prognosis.
‘ctDNA testing, especially using ultrasensitive platforms, could help clinicians make more informed decisions about treatment and give patients a more accurate idea of how their disease might progress,’ he said, adding that ‘more research to validate these tests will help to get them on the agenda for regular clinical use.’
Study senior author Professor Charles Swanton, who holds positions at the UCL Cancer Institute, the Francis Crick Institute and UCLH and is chief investigator of the TRACERx study, noted that lung cancer is one of the most common types of cancer in the UK and has a high relapse rate.
‘It’s vital to understand who would benefit from more aggressive treatment, especially for patients with stage 1 disease who are often diagnosed during CT screening for those at a higher risk,’ he said.
‘Using sensitive ctDNA tests is one way to do this, which we hope will maximise clinical benefit and minimise unnecessary treatment for individual patients.’
Speaking at Hospital Healthcare Europe’s recent Clinical Excellence in Respiratory Care event, Dr Zaheer Mangera,the lung cancer lead at North Middlesex University Hospital NHS Trust in London, said ctDNA tests were among the innovations to watch in lung cancer care, with the Trust involved in a ctDNA pilot in recent months.
Digital health technologies offer opportunities to improve healthcare if integrated appropriately into healthcare systems. A recent study in Germany examining the use of digital health technologies in rheumatology care found that their use and acceptance among patients are increasing. The research highlights the need for ongoing, standardised tracking of digital technologies’ integration into patient care.
The researchers surveyed 337 rheumatology patients from three different clinics in Germany, exploring current acceptance, use and preferences regarding digital health technologies. They also considered the impact of the Covid-19 pandemic on these factors. They analysed the results using descriptive statistics and correlation analysis.
Patients widely accepted digital health technologies as valuable tools in rheumatology care, and the accessibility and flexibility of each one drove their choice of which to use.
Over half of the participants (53%, n=179) reported using digital health technologies, including wearables (21%), mHealth apps (21%), digital therapeutics (9%), electronic prescriptions (9%), video consultations (4%) and at-home blood self-sampling (1%). Users were more likely to have a university education than non-users, with 63.7% of users having a degree versus 27.8% amongst non-users.
Patients identified the main benefits of digital health technologies as being able to access the devices anywhere (72%) and at any time (64%). The main barriers included insufficient user knowledge (49%) and limited information on digital health services (40%).
The researchers highlighted the ‘multidisciplinary digital transformation’ taking place in healthcare, particularly the ‘notable surge in digital technologies’ in rheumatology care. They attributed this to the increasing numbers of patients with rheumatic and musculoskeletal disease and the static and, in some cases decreasing, availability of healthcare professionals in this field.
The study showed that digital health technologies are increasingly accepted and used among rheumatology patients in Germany. Highlighting the opportunities and understanding the obstacles to integrating these technologies into patients’ care will aid the digital transformation in rheumatology care, the researchers said. However, they concluded that a standardised monitoring system needs to be developed to maximise their potential.
Reference
May, S et al. Digital Transformation of Rheumatology Care in Germany: Cross-Sectional National Survey. J Med Internet Res 2025; Sept. 09: DOI: 10.2196/52601.
27th January 2025
Watch all the latest Clinical Excellence event sessions at a time that fits with your busy schedule via Hospital Healthcare Europe (HHE)’s brand new video zone.
Clinical Excellence Catch-up offers a free-to-view selection of on-demand videos bringing you key insights from leading experts in cardiovascular and respiratory care shared at our recent Clinical Excellence events.
The events series focuses on clinical innovation, examples of best practice and the transformation of patient care at Centres of Excellence and other key institutions across the UK.
So, whether you want to revisit some of the fascinating discussions, share the learnings with your team to inspire change at your own hospital, or if you couldn’t make the session and simply want to catch up on everything you missed, visit the Clinical Excellence Catch-up zone now.
Current videos include a panel discussion on managing pulmonary hypertension as a multidisciplinary team (MDT) and an overview of the challenges and management of severe respiratory disease from Ravijyot Saggu, a co-author of the latest European Respiratory Society guideline.
More event session videos will be added to the zone soon, which can be accessed via the dropdown in the Events tab within the main website navigation.
To coincide with events in the Clinical Excellence series, a whole host of additional content and interviews with prominent clinicians from UK Centres of Excellence and other NHS Trusts are being shared on the HHE website – look out for the orange Clinical Excellence tag in the Cardiovascular and Respiratory zones.
This includes a case study from Royal Papworth Hospital on their Enhanced Recovery Unit, which aims to improve the flow and experience of cardiac surgical patients.
And why not read our interview with the Royal Brompton Hospital’s Professor Andy Bush in which he discusses his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, as well as his latest research into the early origins of asthma.
Register now for 2025
The agenda for the spring 2025 Clinical Excellence in Cardiovascular Care event is shaping up to be the best one yet, and registration is now open.
Sign up to be among the first to hear the latest innovations in cardiovascular care from some of the UK’s leading experts, with the opportunity to gain CPD hours at this day-long event.
The spring 2025 Clinical Excellence in Respiratory Care event will be announced soon so watch this space.
A perioperative eHealth tool used alongside standard care has been shown to successfully support older patients with abdominal aortic aneurysm throughout their treatment journey.
The app was well used and valued by patients, providing information and positive lifestyle advice before, during and after operations. Patients also appreciated the ability to share the application with relatives, the researchers found.
What’s more, healthcare staff also saw benefits as the app aided the management of a prehabilitation programme and enhanced the digital transformation of healthcare, decreasing their workload.
In the prospective, single-centre cohort study, patients were offered the opportunity to download the app before undergoing abdominal aortic aneurysm surgery. The app provided a range of information for patients, including information about their condition and the surgical techniques involved (endovascular aneurysm repair and open surgical repair), as well as perioperative lifestyle advice, such as exercise programmes, ensuring a healthy diet rich in protein, geriatric care and advice on stopping smoking or drinking alcohol.
The majority of patients reported positive responses using the eHealth app and valued the ability to share relevant information with their relatives.
Over 90% of patients with abdominal aortic aneurysm installed the app (n=59/65), with 10% deactivating it after installation. The mean age of users was 74, and 85% were male. Users were active on the app, opening it a median of 67 times. The interquartile range (IQR) was 33–127, indicating the range of times that patients interacted with the app.
The satisfaction questionnaire was completed by 90% of the participants, rating their experiences with the eHealth tool on a scale from 0 to 10. The median scores were 8 for guidance (IQR 6–8), 8 for information provision (IQR 6–8), 7 for usefulness (IQR 6–8.5) and 8 for recommendation to others (IQR 6–9).
Seven patients provided more in-depth feedback in a semi-structured interview and described positive experiences, particularly related to healthy lifestyle advice and the ability to share information about their abdominal aortic aneurysm care with relatives.
The researchers said the user data and feedback highlighted several areas for improvement, but they emphasised the wide-reaching benefits of using an eHealth tool for supplementary care in older patients with abdominal aortic aneurysm.
Reference
Gjosha, B et al. Positive Experiences with the Use of an eHealth Smartphone Application During the Treatment of an Abdominal Aortic Aneurysm. Annals of Vascular Surgery; Oct 24: DOI: 10.1016/j.avsg.2024.07.112.
A Spanish study aiming to address the environmental impact of inhalers has highlighted the importance of aligning clinical need and sustainability criteria into prescribing practices.
Focusing on reducing the high carbon footprint of pressurised metered-dose inhalers (pMDIs), the researchers developed a framework promoting the use of eco-friendly alternatives like dry powder inhalers (DPIs) and soft mist inhalers.
pMDIs contribute notably to the carbon footprint of medicines and healthcare, with two puffs of a hydrofluoroalkane (HFA) propelled pMDI being equivalent to driving 2km by car. Therefore, the study’s aim was to create a framework to reduce this environmental burden by implementing greener prescription practices without compromising patients’ health.
The mixed methods research first involved the formation of a multidisciplinary working group, including hospital pharmacists, pulmonologists and academics. A comprehensive database was then developed, incorporating the carbon footprint and other environmental data of inhalers marketed in Spain.
A key element to this was creating a decision-making algorithm integrating both clinical and environmental criteria, allowing healthcare professionals to consider sustainable alternative inhaler types.
The study revealed ‘significant variability in inhaler carbon footprint, with pMDIs showing the highest emissions due to HFA propellants’, the researchers said.
Scenario projections showed that a 10% shift from pMDIs to DPIs could reduce CO2 emissions by up to 40,000 tonnes annually. A 50% shift could save as much as 200,000 tonnes.
The authors concluded that incorporating environmental criteria into inhaler prescribing decisions could substantially reduce the healthcare sector’s carbon footprint and that ‘the decision-making algorithm developed in this study offers a practical tool’ for achieving this.
The study’s findings also highlighted the importance of involving patients in the decision-making process, empowering them to consider the environmental implications of their treatment choices.
Moving forward, the researchers suggested further work was needed to refine the decision-making algorithm and explore its application in other healthcare settings and countries. Additional studies are also required to evaluate the long-term effects of greener inhaler prescribing practices on both patient health and environmental outcomes.
Policymakers should consider incorporating these findings into national healthcare guidelines to promote sustainable prescribing on a broader scale, the researchers added.
Reference
Garin N, Zarate-Tamames B, Lertxundi U, et al. The environmental impact of inhalers: a framework for sustainable prescription practices in Spain. European Journal of Hospital Pharmacy, January 2025. doi: 10.1136/ejhpharm-2024-004402.
Professor Christopher Denton, consultant rheumatologist at the Royal Free Hospital in London, led a recent British Society for Rheumatology guideline working group on managing systemic sclerosis. Here, as lead author of the published recommendations, he explains key aspects of the guideline and highlights new and emerging advances in treatment for this challenging condition.
Systemic sclerosis is a severe and incurable autoimmune rheumatic disease that causes damage and fibrosis in the skin, blood vessels and vital organs. It also impacts hand function, and almost all aspects of everyday living are affected.
It is uncommon, affecting around one in 10,000 of the population. Unfortunately, it has a high mortality and even greater morbidity through its impact on the lungs, heart, kidneys and gastrointestinal tract.1
The first guideline covering the management of systemic sclerosis in all age groups were published in September 2024 by the British Society for Rheumatology following working group discussions among healthcare professionals with expertise in systemic sclerosis, people with lived experience of the condition and patient organisation representatives.2 This is an updated version of an earlier 2015 guideline that only covered adults with this complex disease.3
Systemic sclerosis is a diverse disease, so guidelines need to consider the differences in how people may present with it. Often it takes time to make a firm diagnosis, which can lead to treatment delays.
Early diagnosis using techniques such as capillaroscopy and antinuclear autoantibody testing is important and allows stratification of risk for future complications, including lung fibrosis and severe renal involvement.4
Once diagnosed, there should be a systematic baseline assessment of all the organs that might be affected and regular follow-up testing through the disease course. A particular group highlighted in the new guideline is the subset of cases associated with concurrent malignancy.
This group has certain characteristics that allow for early recognition, including certain antibody associations and clinical features. The approach to these cases is analogous to that taken with adult-onset dermatomyositis.
In line with other recently published recommendations and aligned with the British Society for Rheumatology guideline protocol, young people with systemic sclerosis are included in the recommendations for the first time. This was achieved through strong engagement with the paediatric rheumatology community. For each of the evidence-based recommendations, a statement about relevance to children and adolescent patients is included.
The British Society for Rheumatology guideline includes four key sections:
Each section is framed around key questions that are front and centre of systemic sclerosis management, such as the best approaches to treating heart, lung or gastrointestinal complications. There is also much emphasis on non-lethal manifestations such as digital ulcers as well as non-pharmacological treatments.
The fourth section of the guideline covers specific aspects of service delivery within the NHS. It will help to plan the recommended practice and provide templates and standards for service and patient-specific future audit.
There has been nearly a decade of progress in managing systemic sclerosis, which is captured in the updated guideline.
There are now evidence-based treatments, approved drugs for interstitial lung disease in systemic sclerosis, and more robust support for approaches such as autologous haematopoietic stem cell transplantation. The latter has been shown in robust trials to have a profound benefit for appropriate cases, and the guideline includes specific expert direction on the assessment and evaluation of cases for this procedure.
There is growing support for the treatment of vascular disease, including pulmonary arterial hypertension, and the updated guideline complements guidance from other relevant bodies such as the World Symposium for Pulmonary Hypertension.5
The first major area of progress has been advances in cellular therapy. Large, robust clinical trials and registry studies have confirmed the long-term benefit of autologous haematopoietic stem cell transplantation in poor prognosis systemic sclerosis.6 The new guideline covers this for adults and highlights that it is also a treatment option for juvenile-onset systemic sclerosis.
Critical guidance to help select and evaluate patients so that maximum benefit and minimal harm are achieved is included with simple summaries for case selection. This treatment shows what can be accomplished and provides a pivotal demonstration of disease modification.
Progress has also been made in managing vasculopathy in systemic sclerosis and therefore scleroderma renal crisis, digital ulcer disease, Raynaud’s phenomenon and pulmonary hypertension are all covered clearly in the guideline. These sections summarise evidence-based practice and highlight that systemic sclerosis is as much a cardiovascular disease as a fibrotic condition.7
However, fibrosis of the lung is now the most frequent cause of systemic sclerosis-associated death, and there have been studies providing evidence for treatment.
The guideline includes expert direction on the evaluation and treatment of interstitial lung disease, including a combination of immunosuppression with antifibrotic treatment (nintedanib) in cases of progressive disease.8
Other approaches have been approved based on clinical trial results, including biological therapy with tocilizumab and rituximab.9 These may be especially effective in certain stages and subsets of systemic sclerosis, as indicated in the guideline.
While not yet routinely available in the NHS, it is hoped that the growing evidence base for these biological agents and general utilisation in other global healthcare settings will facilitate access to these treatments in the future. It is likely that, at present, the use will generally be restricted to cases of sclerosis fulfilling the requirements to access rituximab or tocilizumab for other manifestations of overlap syndrome such as arthritis, myositis or vasculitis.
Despite progress in treatment for some of the most serious aspects of systemic sclerosis, including interstitial lung disease, pulmonary hypertension and scleroderma renal crisis, there is still much more to address.
As survival overall has improved, the importance of non-lethal burden is pivotal for people living with systemic sclerosis. Inclusion of people with lived experience in the guideline working group highlighted this challenge, as did the strong involvement and endorsement of the guideline by the charity Scleroderma and Raynaud’s UK.
The British Society for Rheumatology guideline protocol includes an expectation that the guideline will be revised and updated. There is unprecedented interest in systemic sclerosis and its complications from the pharmaceutical industry and many clinical trials are ongoing.
The results of such trials, generally adding new potential treatments to background standard of care immunosuppression, will provide the evidence base for future guidelines. Still, it is likely that as one therapeutic mountain is scaled, another challenging peak will emerge. The updated guideline for systemic sclerosis represents an important milestone in the journey but the final destination is still some way off.
Christopher Denton PhD FRCP FMedSci
Consultant rheumatologist, Royal Free London NHS Foundation Trust, UK
24th January 2025
Good physical fitness combined with muscular strength could reduce cancer patient deaths, a recent study suggests.
Researchers found that tailored exercise plans may prolong life for people living with cancer and boost their chances of survival. The study, published in the British Journal of Sports Medicine, could have implications for clinical practice, with muscle strength exercises employed to increase life expectancy.
The international researchers, led by Edith Cowan University in Australia, pooled data from 42 studies published in English in five databases up to August 2023 to examine whether physical fitness could extend survival rates in cancer patients. The 47,694 patients in the studies had an average age of 64 and had been diagnosed with various types and stages of cancer.
Muscle strength was determined by handgrip strength measurements. Depending on age, a handgrip strength of below 13 kg to below 25 kg was classified as low strength for women. Low strength was classified as below 20 kg to below 40 kg for men. Cardiorespiratory fitness was assessed using either cardiopulmonary exercise testing (CPET) or a six-minute walk test (MWT).
The analysis suggested that both muscular strength and good physical fitness are associated with a significantly lower risk of death from any cause in cancer patients. Patients who maintained strong muscles and good overall fitness had a 31-46% lower risk of dying from any cause compared to those with poor muscle strength and low cardiorespiratory fitness. This risk continued to fall by 11% for each unit increase in muscular strength and 18% for each unit increment in cardiorespiratory fitness.
In patients with advanced-stage cancer (stages 3 and 4), muscle strength and cardiorespiratory fitness were associated with an 8-46% reduced risk of all-cause mortality and a 19-41% lower risk of death from any cause among those with lung or digestive cancers.
‘Our findings highlight that muscle strength could potentially be used in clinical practice to determine mortality risk in cancer patients in advanced stages and, therefore, muscle strengthening activities could be employed to increase life expectancy,’ the researchers concluded.
A previous study published in the same journal suggested that young men with a higher level of cardiorespiratory fitness had a significantly lower risk of developing several cancers in later life.
A version of this article was originally published by our sister publication Nursing in Practice.
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