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Survivors of adult-onset cancer experience increased CVD risk
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The risk for cardiovascular disease appeared greater among adult survivors of certain cancer subtypes, including multiple myeloma, lung cancer, non-Hodgkin’s lymphoma and breast cancer, according to the results of a retrospective study.
Further, survivors who developed cardiovascular disease (CVD) experienced poor OS, results showed.
Saro H. Armenian, DO, MPH
“In the general U.S. population, CVD (ischemic heart disease, stroke or heart failure) is a leading cause of morbidity and mortality, and cardiovascular risk factors (diabetes, hypertension, dyslipidemia) are well-established modifiers of disease risk,” Saro H. Armenian, DO, MPH, director of the Childhood Cancer Survivorship Clinic and director of the division of outcomes research at City of Hope, and colleagues wrote. “Research in childhood and young adult (< 40 years of age at diagnosis) cancer survivors has found a substantially higher risk for CVD when compared with the general population; this is largely attributable to exposure to cardiotoxic therapies at a young age and emergence of new [cardiovascular risk factors] later in life.”
However, little research has focused on the risk for CVD in patients who develop cancer in adulthood, according to study background.
Thus, Armenian and colleagues conducted a retrospective study to compare the magnitude of CVD risk in survivors of adult-onset cancer compared with disease-free controls using data obtained from the electronic health records of a large integrated managed care organization.
The study included data from 36,232 survivors (≥ 2 years) of adult-onset cancer (median age at diagnosis, 60 years; range, 40-96), as well as 73,545 age-, sex- and location-matched noncancer controls.
Prostate cancer served as the most common diagnosis (30.2%), followed by breast cancer (28.8%), colon cancer (7.2%) and melanoma (6%).
Median follow-up was 4.4 years (range, 0-8).
The researchers observed a significantly higher CVD risk among survivors of multiple myeloma (incidence rate ratio [IRR] = 1.7; P < .01), lung or bronchus cancer (IRR = 1.58; P < .01), non-Hodgkin’s lymphoma (IRR = 1.41; P < .01) and breast cancer (IRR = 1.13; P < .01).
However, it appeared that survivors of prostate cancer had a significantly lower risk for CVD than cancer-free controls (IRR = 0.89; P < .01).
The researchers did not observe an increased risk for CVD among survivors of bladder cancer, chronic lymphocytic leukemia, colon cancer, melanoma, rectal cancer, thyroid cancer or uterine cancer.
An exploratory analysis by CVD subtype revealed that survivors of breast cancer, lung or bronchus cancer, CLL, multiple myeloma, and non-Hodgkin’s lymphoma had an increased risk for cardiomyopathy and heart failure (IRR = 1.35-2.52; P < .05).
Survivors of multiple myeloma and non-Hodgkin’s lymphoma had an increased risk for ischemic heart disease (IRR = 1.35-1.54; P < .01), whereas survivors of prostate cancer had a decreased risk for the condition (IRR = 0.86; P < .01).
An increased stroke risk occurred among survivors of lung or bronchus cancer and ovarian cancer (IRR = 1.64-1.85; P < .01). However, prostate cancer survivors had a decreased stroke risk (IRR = .087; P < .01).
Survivors of cancer who had two or more cardiovascular risk factors exhibited a greater risk for CVD than cancer-free controls with less than two cardiovascular risk factors (IRR = 1.83-2.59; P < .01).
Fewer survivors who developed CVD achieved 8-year OS than survivors without CVD (60% vs. 81%; P < .01).
The researchers acknowledged limitations of their study, including the reliance on electronic health records and the potential for improper or incorrect coding. Further, they noted that the decreased CVD risk observed among survivors of prostate cancer may have been due to screening bias.
“Outcomes after the onset of CVD in long-term cancer survivors seem to be especially poor, emphasizing the need for additional studies to characterize the treatment-specific associations with long-term CVD risk, as well as the effect of therapeutic strategies to mitigate this risk,” Armenian and colleagues concluded. – by Cameron Kelsall
Disclosure: Armenian reports no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures.
Perspective
Back to TopTomas Neilan, MD
Survivors of adult-onset cancer who develop new-onset cardiovascular disease (CVD) have a 20% greater absolute increase in late mortality compared with cancer survivors who did not develop CVD, according to a large community-based observation study published in Journal of Clinical Oncology. In a study containing over 36,000 adult cancer survivors from the SEER cancer registry, Armenian and colleagues found that the absolute survival at 8 years was 60% among cancer survivors who developed CVD (eg, ischemic heart disease, stroke and heart failure), compared with 81% among cancer survivors who did not develop CVD.
Additionally, the researchers found that traditional cardiovascular risk factors were increased among cancer survivors and that the presence of traditional cardiovascular risk factors was associated with an increased risk for the development of CVD in this cohort. For example, they found that cancer survivors were more likely to have hypertension, diabetes and dyslipidemia than matched controls and that the presence of two or more traditional cardiovascular risk factors were associated with an approximately twofold increase in the probability of developing significant incidental CVD.
The researchers also tested the association between cancer type and, by inference, also cancer therapy, with each individual CVD. For example, they found that the risk for heart failure was highest among breast cancer, non-Hodgkin’s lymphoma and lung cancer survivors.
The authors acknowledge the limitations of such a study, especially when using ICD-9 coding for the diagnosis of CVD. Additionally, they acknowledge that using hard endpoints may underestimate the burden of CVD by not including diagnoses, such as the development of valvular heart disease atrial fibrillation.
There are over 14 million cancer survivors in the U.S., and that number is expected to increase. The increase in survivors is due to improved cancer detection, characterization and therapies. As a result, there is now a renewed focus on improving the noncancer morbidity and mortality among cancer survivors. These data from Armenian and colleagues significantly add to our understanding of the cardiovascular morbidity and mortality among these at-risk groups, and the field would like to congratulate the researchers for their important and significant contribution.
As the researchers wrote, these studies emphasize “the need for additional studies to characterize the treatment-specific associations with long-term CVD risk as well as the effect of therapeutic strategies to mitigate this risk.”
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