TITLE: Radiotherapy for Cancer Patients with Cardiac Implantable Electronic Devices:
Guidelines
DATE: 25 April 2016
RESEARCH QUESTIONS
1.
What are the evidence-based guidelines regarding screening and identification of cancer
patients with cardiac implantable electronic devices who require radiotherapy?
2.
What are the evidence-based guidelines regarding the use of radiotherapy for cancer
patients with cardiac implantable electronic devices?
3.
What are the evidence-based guidelines regarding the post-procedure monitoring and
management of cancer patients with cardiac implantable electronic devices who have
received radiotherapy?
KEY FINDINGS
Three evidence-based guidelines regarding the use of radiotherapy for cancer patients with
cardiac implantable electronic devices were identified.
METHODS
A limited literature search was conducted on key resources including PubMed, The Cochrane
Library, University of York Centre for Reviews and Dissemination (CRD) databases, ECRI,
Canadian and major international health technology agencies, as well as a focused Internet
search. Filters were applied to limit the retrieval to health technology assessments, systematic
reviews and meta-analyses, and guidelines. Where possible, retrieval was limited to the human
population. The search was also limited to English language documents published between
January 1, 2011 and April 14, 2016. Internet links were provided, where available.
Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in
Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic review s. The intent is to
provide a list of sources of the best evidence on the topic that the Canadian Agency for Drugs and Technologies in Health (CADTH)
could identify using all reasonable efforts within the time allow ed. Rapid responses should be considered along w ith other ty pes of
information and health care considerations. The information included in this response is not intended to replace professional medical
advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also
cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and
emerging health technologies, for w hich little information can be found, but w hich may in future prove to be effective. While CADTH
has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not
make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.
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The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.
SELECTION CRITERIA
One reviewer screened citations and selected studies based on the inclusion criteria presented
in Table 1.
Table 1: Selection Criteria
Population
Intervention
Comparator
Outcomes
Study Designs
Cancer patients (of any age) who have a cardiac implantable electronic
device (CIED) (e.g., pacemaker [PPM], implantable cardioverter defibrillator
[ICD], or cardiac resynchronization therapy [CRT] devices)
Radiotherapy
No comparator required
Evidence-based guidelines regarding:
Q1: Screening and identification of patients
Q2: Use of radiotherapy (e.g., appropriate dose, duration of treatment)
Q3: Post-procedure monitoring and management
Evidence-based guidelines
RESULTS
Three evidence-based guidelines regarding the use of radiotherapy for cancer patients with
cardiac implantable electronic devices were identified.
Additional references of potential interest are provided in the appendix.
OVERALL SUMMARY OF FINDINGS
The recommendations indicate that radiotherapy can safely be used for patients with cardiac
implantable electronic devices (CIEDs)2 with a few considerations. Radiotherapy can cause
damage to CIEDs if the devices are too close to the field of radiation; 3 therefore, if CIEDs are
too close to the focus of radiation, they should be covered with a lead shield 3 or surgically
relocated.2 Patients with CIEDs receiving radiotherapy should be categorized according to their
risk of device failure based on the radiation dose received by their device.1 The categories of
risk are: low (less than two grays [Gy]), medium (two to 10 Gy), and high (greater than 10 Gy). 1
Radiotherapy for Cancer Patients with Cardiac Implantable Electronic Devices
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REFERENCES SUMMARIZED
Guidelines and Recommendations
1.
Hurkmans CW, Knegjens JL, Oei BS, Maas AJ, Uiterwaal GJ, van der Borden AJ, et al.
Management of radiation oncology patients with a pacemaker or ICD: a new
comprehensive practical guideline in The Netherlands. Dutch Society of Radiotherapy and
Oncology (NVRO). Radiat Oncol. 2012;7:198. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528416
PubMed: PM23176563
2.
National Guideline Clearinghouse [Internet]. Rockville (MD): Agency for Healthcare and
Research Quality (ARHQ); [1997] - . Guideline summary: Practice advisory for the
perioperative management of patients with cardiac implantable electronic devices:
pacemakers and implantable cardioverter-defibrillators. An updated report by the
American Society of Anesthesiologists Task Force on perioperative management of
patients with cardiac implantable electronic devices; 2011 [cited 2016 Apr 25]. NGC
summary available:
http://www.guideline.gov/content.aspx?id=34403&search=pacemaker+radiation
See: F. Radiation Therapy
3.
National Guideline Clearinghouse [Internet]. Rockville (MD): Agency for Healthcare and
Research Quality (ARHQ); [1997] - . Guideline summary: Disease-specific approaches. In:
II guidelines for perioperative evaluation; 2011 [cited 2016 Apr 25]. NGC summary
available: http://www.guideline.gov/content.aspx?id=34055&search=pacemaker+radiation
See: Potential Harms, Implanted Pacemakers and B. Intraoperative Period, Radiotherapy
PREPARED BY:
Canadian Agency for Drugs and Technologies in Health
Tel: 1-866-898-8439
www.cadth.ca
Radiotherapy for Cancer Patients with Cardiac Implantable Electronic Devices
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APPENDIX – FURTHER INFORMATION:
Systematic Reviews and Meta-analyses
4.
Munshi A, Agarwal JP, Pandey KC. Cancer patients with cardiac pacemakers needing
radiation treatment: a systematic review. J Cancer Res Ther. 2013 Apr;9(2):193-8.
PubMed: PM23771357
Clinical Practice Guidelines – Methodology Not Specified
5.
Thomas H, Turley A, Plummer C, on behalf of BHRS council. BHRS Guidelines: British
Heart Rhythm Society guidelines for the management of patients with cardiac implantable
electronic devices (CIEDs) around the time of surgery [Internet]. Stratford upon Avon,
Warwickshire (UK): BHRS; 2016 [cited 2016 Apr 25]. Available from:
http://www.bhrs.com/files/files/Guidelines/160216-Guideline,%20Perioperative%20management%20of%20CIEDs.pdf
See: Radiotherapy, page 7
6.
Gauter-Fleckenstein B, Israel CW, Dorenkamp M, Dunst J, Roser M, Schimpf R, et al.
DEGRO/DGK guideline for radiotherapy in patients with cardiac implantable electronic
devices. Strahlenther Onkol. 2015 May;191(5):393-404.
PubMed: PM25739476
7.
The Society of Radiographers [Internet]. Management of cancer patients receiving
radiotherapy with a cardiac implanted electronic device: a clinical guideline recommended
for use by The Royal College of Radiologists, The Society and College of Radiographers
and The Institute of Physics and Engineering in Medicine. London (UK): The Society of
Radiographers (SoR); 2014 [cited 2016 Apr 25]. Available from:
http://www.sor.org/sites/default/files/documentversions/mgmt_of_cancer_patients_with_cied_final_with_logos.pdf
8.
Effects of therapeutic radiation on St. Jude Medical implantable cardiac rhythm devices.
Sylmar (CA): St. Jude Medical; 2013.
9.
Guidelines for managing radiotherapy patients with pacemakers or ICDs. Health Devices.
2013 Mar;42(3):100.
PubMed: PM23593661
10.
NHS Tayside. Management of patients with pacemakers/implantable cardiac defibrillators
and undergoing invasive procedures including radiotherapy [Internet]. Tayside, England:
NHS (National Health Service); 2012 [cited 2016 Apr 25]. Available from:
http://blogs.cmdn.dundee.ac.uk/acutecareguide/files/2012/12/Management-of-devicepatients.pdf
Radiotherapy for Cancer Patients with Cardiac Implantable Electronic Devices
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11.
Crossley GH, Poole JE, Rozner MA, Asirvatham SJ, Cheng A, Chung MK, et al. The Heart
Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus
Statement on the Perioperative Management of Patients with Implantable Defibrillators,
Pacemakers and Arrhythmia Monitors: Facilities and Patient Management. Heart Rhythm.
2011 Jul;8(7):1114-54. Available from: http://www.heartrhythmjournal.com/article/S15475271(10)01387-1/abstract
PubMed: PM 21722856
See: 3.9.4 Therapeutic Radiation, page 1121
Additional References
12.
Public Health England. Safer radiotherapy: radiotherapy newsletter of Public Health
England [Internet]. London (UK): UK Government, Government Digital Service; May 2015
[cited 2016 Apr 25];1. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/430597/Saf
er_RT_No16_StdQ.pdf
See: Guest Editorial, page 4
13.
Boston Scientific. Therapeutic radiation and implantable device systems: a closer look
[Internet]. Marlborough (MA): Boston Scientific; 2012 [cited 2016 Apr 25]. Available from:
https://www.bostonscientific.com/content/dam/bostonscientific/quality/educationresources/english/ACL_Therapeutic_Radiation_20120925.pdf
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