Personalizing cardiovascular disease prevention among breast cancer survivors

Cardiovascular health assessment in routine cancer follow-up in community settings: survivor risk awareness and perspectives

BACKGROUND

Guidelines recommend cardiovascular risk assessment and counseling for cancer survivors. For effective implementation, it is critical to understand survivor cardiovascular health (CVH) profiles and perspectives in community settings. We aimed to (1) Assess survivor CVH profiles, (2) compare self-reported and EHR-based categorization of CVH factors, and (3) describe perceptions regarding addressing CVH during oncology encounters.

METHODS

This cross-sectional analysis utilized data from an ongoing NCI Community Oncology Research Program trial of an EHR heart health tool for cancer survivors (WF-1804CD). Survivors presenting for routine care after potentially curative treatment recruited from 8 oncology practices completed a pre-visit survey, including American Heart Association Simple 7 CVH factors (classified as ideal, intermediate, or poor). Medical record abstraction ascertained CVD risk factors and cancer characteristics. Likert-type questions assessed desired discussion during oncology care.

RESULTS

Of 502 enrolled survivors (95.6% female; mean time since diagnosis = 4.2 years), most had breast cancer (79.7%). Many survivors had common cardiovascular comorbidities, including high cholesterol (48.3%), hypertension or high BP (47.8%) obesity (33.1%), and diabetes (20.5%); 30.5% of survivors received high cardiotoxicity potential cancer treatment. Less than half had ideal/non-missing levels for physical activity (48.0%), BMI (18.9%), cholesterol (17.9%), blood pressure (14.1%), healthy diet (11.0%), and glucose/ HbA1c (6.0%). While > 50% of survivors had concordant EHR-self-report categorization for smoking, BMI, and blood pressure; cholesterol, glucose, and A1C were unknown by survivors and/or missing in the EHR for most. Most survivors agreed oncology providers should talk about heart health (78.9%).

CONCLUSIONS

Tools to promote CVH discussion can fill gaps in CVH knowledge and are likely to be well-received by survivors in community settings.

TRIAL REGISTRATION

NCT03935282, Registered 10/01/2020.

Effect of aspirin use on survival benefits of breast cancer patients: A meta-analysis

OBJECTIVE

The purpose of this study is to investigate whether aspirin improves the prognosis of breast cancer patients by meta analysis.

METHODS

Searched PubMed, EMBASE, and other databases for literature on the relationship between aspirin use and breast cancer prognosis, with the deadline of October 2019. The related results of all-cause death, breast cancer-specific death, and breast cancer recurrence/metastasis were extracted to combine the effect amount. The sensitivity analysis and published bias analysis were carried out for the included data. Stata12.0 software was used to complete all statistical analysis.

RESULTS

A total of 13 papers were included in the study, including 142,644 breast cancer patients. The results of meta-analysis showed that patients who took aspirin were associated with lower breast cancer-specific death (HR = 0.69, 95% CI = 0.61-0.76), all-cause death (HR = 0.78, 95% CI = 0.71-0.84), and risk of recurrence/metastasis (HR = 0.91, 95% CI: 0.82-1.00).

CONCLUSIONS

Aspirin use may improve all-cause mortality, specific mortality, and risk of recurrence/metastasis in patients with breast cancer.

The benefits of exercise in cancer patients and the criteria for exercise prescription in cardio-oncology

Cancer and cardiovascular diseases are the leading causes of death in high-income countries. Cardiovascular complications can be found in cancer patients, being the result of so-called 'cardio-toxicity'. Therefore, it becomes essential to thoroughly investigate the origin of cardiac damage and the strategy to prevent it or to reverse the negative remodelling associated with cardiotoxicity. In this review the beneficial effects of physical exercise in cancer patients were analysed, particularly to prevent cardio-toxicity before its clinical manifestation. According to the relevance of exercise, we suggest strategies for exercise prescription with a tailored approach in these patients. In conclusion, physical exercise seems to be a promising and effective treatment for cancer patients during and after therapy and seems to counteract the negative effects induced by drugs on the cardiovascular system. Exercise prescription should be tailored according to patient's individual characteristics, to the drugs administered, to the personal history, and to his/her response to exercise, taking into account that different types of training can be prescribed according also to the patient's choice. A cardiological evaluation including exercise testing is essential for an appropriate prescription of exercise in these patients.

The Association between Hypertension and Race/Ethnicity among Breast Cancer Survivors

PURPOSE

Hypertension is a significant, modifiable risk factor for cardiovascular disease (CVD). African American women who are diagnosed with early-stage breast cancer have a significantly higher risk of premature death due to CVD. The purpose of this study was to examine the association between hypertension and race/ethnicity among breast cancer survivors using data from the National Health and Nutrition Examination Surveys 1999-2014.

METHODS

Non-Hispanic African American and non-Hispanic White women who were diagnosed with breast cancer were identified. Hypertension was defined as taking medication to treat hypertension, having a systolic blood pressure ≥ 140, or a diastolic blood pressure ≥ 90. Modified Poisson regression was performed to estimate the prevalence ratios (PR) and corresponding 95% confidence intervals (CI) for race/ethnicity, as it relates to hypertension controlling for potential confounders.

RESULTS

Of the 524 breast cancer survivors included in our study, 107 (20.4%) were African American and 417 (80.0%) were White. After adjusting for age, marital status, education, annual household income, health insurance, smoking and drinking status, physical inactivity, obesity, and diabetes, African American breast cancer survivors had a 30% higher prevalence of hypertension (PR = 1.30 [95% CI, 1.11-1.52]) than White breast cancer survivors.

CONCLUSIONS

These results indicate that African American breast cancer survivors have a significantly higher risk of CVD due to hypertension even after controlling for other comorbid conditions such as diabetes and obesity.

The role of cardiac magnetic resonance imaging in the detection and monitoring of cardiotoxicity in patients with breast cancer after treatment: a comprehensive review

The use of chemotherapy medicines for breast cancer (BC) has been associated with an increased risk of cardiotoxicity. In recent years, there have been growing interests regarding the application of cardiovascular magnetic resonance (CMR) imaging, a safe and noninvasive modality, with the potential to identify subtle morphological and functional changes in the myocardium. In this investigation, we aimed to review the performance of various CMR methods in diagnosing cardiotoxicity in BC, induced by chemotherapy or radiotherapy. For this purpose, we reviewed the literature available in PubMed, MEDLINE, Cochrane, Google Scholar, and Scopus databases. Our literature review showed that CMR is a valuable modality for identifying and predicting subclinical cardiotoxicity induced by chemotherapy. The novel T1, T2, and extracellular volume mapping techniques may provide critical information about cardiotoxicity, in addition to other CMR features such as functional and structural changes. However, further research is needed to verify the exact role of these methods in identifying cardiotoxicity and patient management. Since multiple studies have reported the improvement of left ventricular performance following the termination of chemotherapy regimens, CMR remains an essential imaging tool for the prediction of cardiotoxicity and, consequently, decreases the mortality rate of BC due to heart failure.

Risk of comorbid cardiovascular disease in Korean long-term cancer survivors

BACKGROUND

Cardiovascular disease (CVD) is a common cause of death in cancer survivors. We evaluated the risk of comorbid CVD in long-term cancer survivors according to specific cancer site.

METHODS

Study subjects included 47,171 Koreans aged over 40 years who visited a health promotion centre between 2010 and 2012. Information on CVD and cancer was obtained from self-report. Comorbid CVD was defined as stroke, myocardial infarction or angina pectoris. The risk of comorbid CVD in survivors was compared with that in non-cancer subjects using multiple logistic regression analysis.

RESULTS

Among cancer survivors (n = 3,753), 330 events of CVD were reported. Age- and sex-adjusted analysis showed that odds ratio (OR) for comorbid CVD in survivors was 1.52 (95% confidence interval: 1.34-1.72) compared to non-cancer subjects (n = 43,418). After adjusting for health-related behaviour and medical history, only lung cancer survivors had 2.44 (1.01-5.89)-fold higher OR for CVD. In stratified analysis, significantly higher OR for CVD was evident in lung cancer survivors with hypertension who did not perform regular physical exercise.

CONCLUSIONS

Adult cancer survivors may have an increased risk of comorbid CVD that might be mediated in part by known cardiovascular risk factors depending on the specific cancer site.

Cardiovascular disease and mortality after breast cancer in postmenopausal women: Results from the Women's Health Initiative

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among older postmenopausal women. The impact of postmenopausal breast cancer on CVD for older women is uncertain. We hypothesized that older postmenopausal women with breast cancer would be at a higher risk of CVD than similar aged women without breast cancer and that CVD would be a major contributor to the subsequent morbidity and mortality.

Methods

In a prospective Women’s Health Initiative study, incident CVD events and total and cause-specific death rates were compared between postmenopausal women with (n = 4,340) and without (n = 97,576) incident invasive breast cancer over 10 years post-diagnosis, stratified by 3 age groups (50–59, 60–69, and 70–79).

Results

Postmenopausal women, regardless of breast cancer diagnosis, had similar and high levels of CVD risk factors (e.g., smoking and hypertension) at baseline prior to breast cancer, which were strong predictors of CVD and total mortality over time. CVD affected mostly women age 70–79 with localized breast cancer (79% of breast cancer cases in 70–79 age group): only 17% died from breast cancer and CVD was the leading cause of death (22%) over the average 10 years follow up. Compared to age-matched women without breast cancer, women age 70–79 at diagnosis of localized breast cancer had a similar multivariate-adjusted hazard ratio (HR) of 1.01 (95% confidence interval [CI]: 0.76–1.33) for coronary heart disease, a lower risk of composite CVD (HR = 0.84, 95% CI: 0.70–1.00), and a higher risk of total mortality (HR = 1.20, 95% CI: 1.04–1.39).

Conclusion

CVD was a major contributor to mortality in women with localized breast cancer at age 70–79. Further studies are needed to evaluate both screening and treatment of localized breast cancer tailored to the specific health issues of older women.

Cardiovascular risk and communication among early stage breast cancer survivors

OBJECTIVE

African American (AA) women have disproportionately high rates of cardiovascular (CV) risk factors that, coupled with potentially cardiotoxic breast cancer (BC) therapies, place them at risk of adverse CV outcomes. The purpose of this study was to assess CV risk factors among white and AA BC survivors and perceptions of patient-provider CV-related communication and post-treatment information needs.

METHODS

Early-stage, English-speaking BC survivors were recruited through community-based survivorship organizations/clinics in New Jersey. Qualitative, semi-structured interviews and a brief survey of socio-demographics and comorbidities were conducted.

RESULTS

BC survivors reported high rates of CV risk factors. Most reported their health as good/excellent despite their cancer history and CV risk profile. Approximately half of overweight/obese BC survivors reported no weight-related conversation with their health care team and, among those who reported discussion, 36% indicated it was self-initiated and dismissed. More than half of BC survivors' reported a desire for lifestyle-related information and guidance.

CONCLUSION

BC survivors may not understand how their separate, yet cumulative, health issues can impact their CV risk.

PRACTICE IMPLICATIONS

Patient-provider communication on behavioral risk factor modification and CV risk is needed, particularly among at-risk subgroups such as AA and obese BC survivors, to improve BC and CV outcomes.

Single subject design: Use of time series analyses in a small cohort to understand adherence with a prescribed fluid restriction

PURPOSE

This paper presents a secondary in-depth analysis of five persons with heart failure randomized to receive an education and behavioral intervention on fluid restriction as part of a larger study.

METHODS

Using a single subject analysis design, time series analyses models were constructed for each of the five patients for a period of 180 days to determine correlations between daily measures of patient reported fluid intake, thoracic impedance, and weights, and relationships between patient reported outcomes of symptom burden and health related quality of life over time.

RESULTS

Negative relationships were observed between fluid intake and thoracic impedance, and between impedance and weight, while positive correlations were observed between daily fluid intake and weight.

CONCLUSIONS

By constructing time series analyses of daily measures of fluid congestion, trends and patterns of fluid congestion emerged which could be used to guide individualized patient care or future research endeavors. Employment of such a specialized analysis technique allows for the elucidation of clinically relevant findings potentially disguised when only evaluating aggregate outcomes of larger studies.

Medication use by early-stage breast cancer survivors: a 1-year longitudinal study

Purpose

The aim of this study is to characterize the patterns of medication use by early-stage breast cancer (ESBC) survivors from diagnosis to 1 year post-chemotherapy.

Methods

A single-center longitudinal study was conducted with ESBC patients diagnosed between December 2011 and June 2014. Data on the medication use of individual patients were retrieved from prescription databases, supplemented by records from the National Electronic Health Records. The data covered the period from ESBC diagnosis to 1 year post-chemotherapy. Medication types were classified according to the World Health Organization’s Anatomical Therapeutic Chemical classification system, and medication for chronic diseases was created by adapting a list of 20 chronic diseases provided by the U.S. Department of Human and Health Services.

Results

Of the 107 patients involved in the study (mean age 51.1 ± 8.4 years; 78.5 % Chinese), 46.7 % manifested non-cancer comorbidities, of which hypertension (24.3 %) was the most prevalent, followed by hyperlipidemia (13.1 %) and diabetes (5.6 %). Calcium channel blockers (12.1 %) and lipid-modifying agents (11.2 %) were the most common chronic medication types used before chemotherapy, and their use persisted during chemotherapy (10.3 and 11.2 %, respectively) and after chemotherapy (11.2 and 13.1 %, respectively). Hormonal therapy was the predominant post-chemotherapy medication (77.6 %). A statistically significant increase (p < 0.0001) was observed in the mean number of chronic disease medication classes prescribed to patients between the pre-chemotherapy (0.53 ± 1.04) and chemotherapy (0.62 ± 1.08) periods and between the chemotherapy and post-chemotherapy (1.63 ± 1.35) periods.

Conclusions

There is an increase in trend of chronic medication usage in breast cancer survivors after cancer treatment. This study provides important insights into the design of medication management programs tailored to this population. Future studies should incorporate a control population to improve the interpretation of study results.