Left Ventricular Ejection Fraction Measurement and Doxorubicin-Based Chemotherapy in Patients with Diffuse Large B-Cell Lymphoma

Purpose:

Doxorubicin-based chemotherapy (DOX) is commonly administered to patients with diffuse large B-cell lymphoma (DLBCL). Prior to chemotherapy, left ventricular ejection fraction (LVEF) is routinely measured to assess left ventricular dysfunction. While LVEF screening is recommended by many national regulatory bodies, evidence supporting the usefulness of LVEF measurement prior to administering DOX is lacking. Our goal was to perform a retrospective analysis of patients with DLBCL to establish (1) how often LVEF was measured prior to administering DOX, and (2) whether the chemotherapy regimen was modified based on LVEF values. As cumulative doses of doxorubicin greater than 400 mg/m² have been associated with an increased risk of congestive heart failure (CHF), we also determined the incidence of CHF in patients with DLBCL who did receive DOX.

Patients and Methods:

We identified 268 patients diagnosed with DLBCL at Virginia Mason Medical Center between 2001 and 2012 and collected the following data: age at diagnosis; stage of lymphoma; type of chemotherapy given; cumulative doxorubicin dose (mg/m²); LVEF status; and incidence of CHF or cardiac disease. We also compared the number of CHF risk factors between patients who did and did not have LVEF measured. Statistical analyses included a Fischer’s exact or Chi-squared test to compare study groups as well as the number of CHF risk factors. The level of significance was set at a P value of < 0.05.

Results:

LVEF was measured in 238 patients (89%) prior to initiation of chemotherapy. LVEF values were normal in 225 patients (95%) and low (< 50%) in 13 patients (5%). Of the patients with normal LVEF, 193 received DOX (86%), and of these patients, 14 developed CHF post-treatment (7%). For the 13 patients with low LVEF, 8 received DOX (62%) and 1 developed post-treatment CHF (13%). The remaining thirty patients did not have LVEF measured and none received DOX. Of the 268 patients studied, 176 are alive (66%) and 3 were lost to follow-up. The mean follow-up time was 43 months (range 3 d to 12.1 y). The mean number of CHF risk factors did not differ between patients who did and did not have LVEF measured (1.70 vs. 1.65, P = 0.87).

Conclusion:

Our results suggest that the decision to administer DOX was not directly affected by LVEF values. These findings challenge the existing policy of routinely screening patients with DLBCL with echocardiograms or MUGA scans prior to treatment.