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CVD in cancer survivors: Stick to the basics of prevention
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Continued improvements in cancer prevention and treatment with a subsequent decline in mortality rates have led to a rapidly growing population of survivors such that the American Cancer Society predicts that by 2024 there will be 19 million long-term cancer survivors in the United States. As a result, we are witnessing a paradigm shift with a growing emphasis on reducing long-term morbidity and mortality in cancer survivors.
CVD is the most common reason for hospitalization and the leading cause of non-cancer-related death for survivors. Yet, proven preventive strategies appear to be underutilized and traditional cardiac risk factors under-recognized in this high-risk population. In response, the National Comprehensive Cancer Network and American Society of Clinical Oncology have recently released survivorship guidelines.
Despite the complexities of individual cancer therapies and their potential effect on the heart and vascular systems, the majority of CVD risk in this population is driven by traditional CV risk factors. Accordingly, providers caring for cancer survivors should stick to the basics of primary and secondary prevention. Helpful measures can be seen in the Table.
Primary prevention
Risk discussions should begin with the Pooled Cohort Risk Equation (http://tools.acc.org/ASCVD-Risk-Estimator/) as created for the 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk. Using this tool, risk can be estimated quantitatively and then used to frame the discussion regarding potential lifestyle and therapeutic interventions. Multiple cardiology society guidelines support interventions based on risk.
Lifestyle interventions are generally regarded as the first step before or in conjunction with pharmacotherapy for individuals with increased risk for CVD. The AHA developed a framework called Life’s Simple 7, which includes ideal health behaviors (nonsmoking, normal BMI, physical activity at goal levels and a healthy diet) and ideal health factors (cholesterol < 200 mg/dL, BP < 120/< 80 mm Hg and a fasting glucose < 100 mg/dL). Survivorship guidelines note that adherence to these factors can lower the incidence of CVD with the strongest data among survivors of breast and prostate cancer.
Secondary prevention
Cancer survivors with established CVD should be treated with the same proven therapeutic agents as the general population. The most robust data in this domain come from the treatment of chemotherapy-induced cardiomyopathy, with most experts recommending the use of HF medications for those with asymptomatic or symptomatic cardiac dysfunction from chemotherapy.
Conclusion
Until rigorously conducted studies prove the efficacy of primary and secondary interventions in the cancer survivor population, it is most reasonable to treat them as any other individual with elevated risk for CVD. Although the field of cardio-oncology blooms in response to an ever-growing and complex armamentarium of cancer therapeutics, providers would do best to remember that the most benefit to these patients can be achieved through an emphasis on the basics of prevention.
- References:
- Goff DC, et al. Circulation. 2013;doi:10.1161/01.cir.0000437741.48606.98.
- Goff DC, et al. J Am Coll Cardiol. 2013;doi:10.1016/j.jacc.2013.11.005.
- Pooled Cohort Risk Equation. http://tools.acc.org/ASCVD-Risk-Estimator/. Accessed Dec. 13, 2017.
- For more information:
- Kristopher Swiger, MD, is a cardiology and cardio-oncology fellow at Vanderbilt University Medical Center. He can be reached at kristopher.swiger@vanderbilt.edu.
Disclosure: Swiger reports no relevant financial disclosures.