How do I manage a patient with oral cancer and poor left ventricular (LV) ejection fraction who is unwilling to consent to high-risk treatments?

Management of Oral Cancer with Poor Ejection Fraction and Refusal of High-Risk Consent

For a patient with oral cancer and poor left ventricular ejection fraction who refuses high-risk treatment consent, you should pursue a multidisciplinary cardio-oncology approach that optimizes cardiac function before cancer therapy, considers less cardiotoxic treatment alternatives, and implements shared decision-making that respects patient autonomy while maximizing both cancer control and cardiac safety. 1

Initial Cardio-Oncology Assessment

• Quantify the cardiac dysfunction precisely with baseline echocardiography (preferably with strain imaging) or cardiac MRI to establish the exact LVEF and assess for diastolic dysfunction, as this determines treatment feasibility and risk stratification 1

• Measure cardiac biomarkers (troponin I or T, BNP or NT-proBNP) at baseline, as these help risk-stratify patients with preexisting significant cardiovascular disease who are at highest risk for perioperative complications 1

• Establish early collaboration between oncology, cardiology, and anesthesiology teams before any treatment decisions, as close interdisciplinary coordination is essential to avoid unnecessary discontinuation of cancer therapy while ensuring cardiovascular safety 1

Cardiac Optimization Strategy

• Initiate guideline-directed medical therapy for heart failure with ACE inhibitors or ARBs and beta-blockers if not already on these medications, as prophylactic use may reduce cardiotoxicity risk even in patients with baseline cardiac dysfunction 1

• Consider statins if hyperlipidemia is present, as patients may benefit from lipid-lowering therapy during active cancer treatment, especially if cardiotoxic chemotherapy is planned 1

• Optimize volume status carefully to ensure adequate cardiac output without excessive left atrial pressure elevation, as patients with LV failure have reduced cardiac compliance and are highly preload-dependent 2

Modified Cancer Treatment Approach

Surgical Considerations

• Anesthetic management requires specialized planning for patients with LV failure, including maintenance of sinus rhythm, careful rate control to optimize diastolic filling time, and avoidance of tachycardia which shortens filling time and decreases cardiac output 2

• Use invasive hemodynamic monitoring and intraoperative transesophageal echocardiography to guide management during surgery, with phenylephrine or norepinephrine as preferred vasopressors rather than agents that reduce preload 2

• Consider levosimendan perioperatively in patients with severe LV dysfunction to reduce risk of low cardiac output syndrome, particularly if surgical resection is planned 2

Alternative Treatment Modalities

• Radiation therapy may be preferable to surgery in patients with poor cardiac reserve who cannot tolerate major surgical procedures, though mediastinal and left-sided chest radiation can affect the cardiovascular system and requires cardiac monitoring 1

• If chemotherapy is necessary, avoid or minimize anthracycline-based regimens in patients with baseline cardiac dysfunction, as these agents carry the highest risk of cardiotoxicity and heart failure 1

• Select less cardiotoxic chemotherapy alternatives when possible, recognizing that altering cancer treatment without strong supportive data may put patients at risk of under-treatment, but this must be balanced against cardiac safety 1

Addressing the Consent Issue

Shared Decision-Making Framework

• Quantify and communicate specific risks using the patient's actual LVEF, comorbidities, and proposed treatment plan rather than generic "high-risk" terminology, as patients deserve precise information about their individual risk profile 1

• Present treatment options in a tiered approach:

  • Most aggressive/curative option with highest cardiac risk
  • Intermediate options with modified surgical approach or radiation-based treatment
  • Palliative/supportive care focused on quality of life 3

• Emphasize that oral cancer is highly lethal without treatment (approximately 50% survival overall, but 80% with early detection and treatment), making some level of intervention critical even with cardiac comorbidity 4, 5

Risk Mitigation Strategies

• Offer staged procedures if feasible, allowing cardiac recovery between interventions rather than a single high-risk operation 2

• Propose intensive perioperative cardiac monitoring with ICU-level care, invasive monitoring, and cardiology consultation throughout the perioperative period to maximize safety 2

• Consider regional anesthesia techniques when anatomically feasible to reduce systemic hemodynamic stress compared to general anesthesia 2

Cardiac Surveillance During Cancer Treatment

• Implement serial cardiac imaging using the same modality at the same facility for reproducibility, with echocardiography (including strain imaging when available) or cardiac MRI 1

• Monitor cardiac biomarkers (troponin and BNP/NT-proBNP) in conjunction with cancer treatment safety laboratories if chemotherapy is used, as elevations may indicate developing cardiotoxicity requiring intervention 1

• Maintain close cardiology follow-up throughout cancer treatment with more frequent assessments in high-risk patients, as early detection of cardiac decompensation allows for intervention before irreversible damage 1

Critical Pitfalls to Avoid

• Do not delay cancer treatment indefinitely while attempting to optimize cardiac function, as oral cancer progression during prolonged delays may eliminate curative treatment options and worsen prognosis 6, 3

• Avoid assuming all patients with reduced LVEF cannot tolerate cancer treatment, as many can be successfully managed with appropriate cardiac optimization, modified treatment regimens, and intensive monitoring 1

• Do not proceed with high-risk surgery without documented informed consent, but continue engaging the patient with clear risk-benefit discussions and alternative options rather than abandoning treatment 1

• Recognize that "poor ejection fraction" requires specific quantification (LVEF <35% versus 35-50% versus >50%) as management strategies and risk profiles differ substantially across these ranges 1, 2

When Conservative Management is Appropriate

• If LVEF is severely reduced (<35%) and patient refuses any risk, focus on oral care protocols to minimize complications, pain management, and nutritional support while continuing cardiac optimization 7

• Consider palliative radiation for local control and symptom management even if curative intent is not feasible, as this may improve quality of life with lower cardiac risk than surgery 1

• Maintain regular dental surveillance and professional oral care to prevent secondary complications that could worsen overall health status 7

The key is balancing the high mortality of untreated oral cancer against cardiac risk through individualized treatment modification, aggressive cardiac optimization, and persistent patient engagement rather than accepting treatment refusal as final. 1, 3