Childhood cancer survivors at greater risk for death after major cardiovascular event
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Childhood cancer survivors appeared significantly more likely than the general public to die after a major cardiovascular event, according to study results.
The findings — published in Journal of the American College of Cardiology — could serve as the foundation for guideline updates to more proactively address cardiovascular risk among childhood cancer survivors, researchers concluded.
Investigators evaluated data from the Childhood Cancer Survivors Study, which includes 25,658 childhood cancer survivors and more than 5,000 of their siblings.
They also reviewed data from the CARDIA study. CARDIA — which included a racially diverse cohort (n = 5,115) of individuals aged 18 to 30 years at the time of enrollment — aimed to investigate the development of coronary artery disease among young adults.
Analysis of Childhood Cancer Survivors Study data showed 1,780 survivors and 91 siblings experienced a cardiovascular event.
Compared with siblings, childhood cancer survivors exhibited significantly higher rates of 10-year all-cause mortality after heart failure (30% vs. 14%; HR = 7.32; 95% CI, 2.56-20.89), coronary artery disease (36% vs. 14%; HR = 5.54; 95% CI, 2.37-12.93) or stroke (29% vs. 4%; HR = 3.57; 95% CI, 1.12-11.37).
Childhood cancer survivors experienced cardiovascular events at younger ages than members of the CARDIA cohort (median, 31 years vs. 57 years), and all-cause mortality after coronary artery disease appeared significantly elevated among childhood cancer survivors (HR = 1.85; 95% CI, 1.16-2.95).
“We know things like high blood pressure and high cholesterol can increase anyone’s risk for cardiovascular events, but there’s evidence that these risks increase exponentially among survivors of childhood cancer,” Wendy J. Bottinor, MD, cardio-oncologist at VCU Massey Comprehensive Cancer Center and VCU Health Pauley Heart Center, told Healio. “These findings may suggest a need to reconsider the thresholds we use for starting blood pressure and cholesterol medications [for] survivors of childhood cancers. We don’t want to assume that because these patients are young, we don’t need to aggressively address these issues.”
Healio spoke with Bottinor about the findings and their potential implications.
Healio: What motivated you to conduct this study?
Bottinor: We knew survivors of childhood cancer have an increased risk for cardiovascular disease. We wanted to examine how these cardiovascular events — heart attack, stroke or heart failure — affect an individual’s long-term risk for mortality. Once a survivor has a heart attack, does their risk become similar to that of someone in the general population who has also had a heart attack, or is there still a residually higher risk due to the background of a previous cancer diagnosis?
Healio: How did you conduct the study?
Bottinor: We utilized two very robust databases. The first was the Childhood Cancer Survivor Study, a multi-institutional database housed at St. Jude Children’s Research Hospital that has been ongoing for several decades. Our other source of data was CARDIA, established in the 1980s with the purpose of learning about how environmental exposures and health in young adulthood impact the future development of cardiovascular disease. CARDIA recruited 50% white and 50% Black participants. That is important because risks for cardiovascular disease and outcomes differ based on racial descent.
Healio: What did you find?
Bottinor: We found risk for death after a cardiovascular event was higher among childhood cancer survivors than siblings.
When we compared childhood cancer survivors with individuals from CARDIA, risk for death after a cardiovascular event was similar. However, on average, people in CARDIA were about 2 decades older than childhood cancer survivors when they experienced an event.
We know age plays a role in outcomes after major health events. If someone is 70 and has a heart attack, we might expect a less robust outcome than we’d see with someone who is 50. So, it seems meaningful that we’re seeing childhood cancer survivors who are having similar outcomes from these events as people who are 2 decades older than them. That’s very, very surprising, and I think it’s important for us to recognize.
Healio: What are the potential implications of these findings?
Bottinor: A number of studies have shown that the majority of childhood cancer survivors do not receive specific care for late effects. Most survivors eventually transition back to general care and they don’t necessarily have access to specialized resources like survivorship clinics. These data help show we need to recognize the fact survivors have unique risks compared with other similar-aged individuals, and the care they receive should align with this. It’s not a one-size-fits-all model. Survivors of childhood cancer need care that recognizes what they’ve been through.
Healio: What can oncologists do to ensure optimal care for childhood cancer survivors?
Bottinor: When oncologists notice changes among cancer survivors like slightly elevated cholesterol or blood pressure, our hope is that they will talk with the patient about strategies to address this. This might include identifying local resources like survivorship clinics or cardio-oncology specialists, or encouraging patients to have more focused conversations with their primary care clinicians. It’s important to be in tune with the fact that these elevated risks factors exist, and to recognize the need to catch them as early as possible.
Healio: What are the next steps?
Bottinor: Ultimately, our goal is to change the guidelines. If you look at cardiology guidelines put out by authorities like American Heart Association and American College of Cardiology, their thresholds for treating things like high cholesterol or high blood pressure are different based on patients’ medical histories. For example, if a patient has had a previous heart attack, the guidelines would have a lower threshold for starting blood pressure or cholesterol medication compared with someone with no history of heart attack. However, these guidelines do not account for whether someone has previously been diagnosed with or treated for cancer. That’s a major area that we would like to see updated. We want to perform robust research — with this publication being the start of that — to demonstrate that individuals who are survivors of cancer have a higher risk. The thresholds should be lower for when we start aggressively treating risk factors.
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For more information:
Wendy J. Bottinor, MD, can be reached at VCU Massey Comprehensive Cancer Center, 417 N. 11th St., Richmond, VA 23298; email: askmassey@vcu.edu.
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