Competing risks of cancer mortality and cardiovascular events in individuals with multimorbidity

Cancer and Heart Failure: Dangerous Liaisons

Cancer and heart failure (HF) are increasingly relevant worldwide, both from an epidemiologic and clinical point of view. This review aims to explore the relationship between cancer and HF by underscoring risk factors and disclosing the cardiotoxic effects of the current chemotherapy agents. We also deal with the current evidence on the diagnosis and management of HF related to cancer therapy. Finally, we will address the main gaps in knowledge and future perspectives in this field.

Implications and hidden toxicity of cardiometabolic syndrome and early-stage heart failure in carfilzomib-induced cardiotoxicity

BACKGROUND AND PURPOSE

Cancer therapy-related cardiovascular adverse events (CAEs) in presence of comorbidities, are in the spotlight of the cardio-oncology guidelines. Carfilzomib (Cfz), indicated for relapsed/refractory multiple myeloma (MM), presents with serious CAEs. MM is often accompanied with co-existing comorbidities. However, Cfz use in MM patients with cardiometabolic syndrome (CMS) or in heart failure with reduced ejection fraction (HFrEF), is questionable.

EXPERIMENTAL APPROACH

ApoE-/- and C57BL6/J male mice received 14 weeks Western Diet (WD) (CMS models). C57BL6/J male mice underwent permanent LAD ligation for 14 days (early-stage HFrEF model). CMS- and HFrEF-burdened mice received Cfz for two consecutive or six alternate days. Daily metformin and atorvastatin administrations were performed additionally to Cfz, as prophylactic interventions. Mice underwent echocardiography, while proteasome activity, biochemical and molecular analyses were conducted.

KEY RESULTS

CMS did not exacerbate Cfz left ventricular (LV) dysfunction, whereas Cfz led to metabolic complications in both CMS models. Cfz induced autophagy and Ca2+ homeostasis dysregulation, whereas metformin and atorvastatin prevented Cfz-mediated LV dysfunction and molecular deficits in the CMS-burdened myocardium. Early-stage HFrEF led to depressed LV function and increased protein phosphatase 2A (PP2A) activity. Cfz further increased myocardial PP2A activity, inflammation and Ca2+-cycling dysregulation. Metformin co-administration exerted an anti-inflammatory potential on the myocardium without improving LV function.

CONCLUSION AND IMPLICATIONS

CMS and HFrEF seem to exacerbate Cfz-induced CAEs, by presenting metabolism-related hidden toxicity and PP2A-related cardiac inflammation, respectively. Metformin retains its prophylactic potential in the presence of CMS, while mitigating inflammation and Ca2+ signalling dysregulation in the HFrEF myocardium.

A COVID-19 Diagnosis Like an Avalanche Triggers a Series of Adverse Events but Saves a Life in the End

Patients diagnosed with cancer are less frequently covered by preventive measures for cardiovascular diseases. The frequent co-occurrence of these diseases makes it necessary to apply parallel diagnostics and cardiological treatment with anti-cancer therapy. Frequently. multidisciplinary team discussions are needed. Case report: We present a case of a 73-year-old former smoker with hyperlipidemia, type 2 diabetes, and arterial hypertension, after a partial right nephrectomy in 2005 due to kidney cancer, diagnosed with SARS-CoV-2 infection in April 2022. Subsequent chest imaging showed a 20 mm focal lesion in the left lung further classified as a small-cell neuroendocrine carcinoma. Unexpectedly, the patient was hospitalized due to ST-segment elevation inferior left ventricular (LV) myocardial infarction. It was treated successfully with percutaneous coronary angioplasty (PCI) of the circumflex and first marginal artery with drug-eluting stent (DES) implantation. One day later, PCI of the left anterior artery was performed with two DES implantation; however, heart failure (HF) with a reduced left ventricle ejection fraction of 30% was diagnosed. One month later, the patient required hospitalization again due to HF decompensation, and cardiological treatment was optimized with flozin in addition to standard HF therapy. Subsequently, after cardiological approval the patient qualified for chemotherapy with the cisplatin-etoposide regimen. Therapy was continued for 6 months without HF decompensation and significant deterioration in renal function. After that, the patient underwent radical radiotherapy. Follow-up chest computed tomography scans showed regression of the neoplastic lesion. Conclusions: The coincidence of newly recognized cancer and inflammatory disease might contribute to and provoke serious cardiological events. To reduce the risk of cardiovascular complications, periodic cardiological surveillance and optimal pharmacotherapy are required.

Cancer and heart disease: associations and relations

Emerging evidence supports that cancer incidence is increased in patients with cardiovascular (CV) disease and heart failure (HF), and patients with HF frequently die from cancer. Recently, data have been generated showing that circulating factors in relation to HF promote tumour growth and development in murine models, providing proof that a causal relationship exists between both diseases. Several common pathophysiological mechanisms linking HF to cancer exist, and include inflammation, neuro‐hormonal activation, oxidative stress and a dysfunctional immune system. These shared mechanisms, in combination with risk factors, in concert may explain why patients with HF are prone to develop cancer. Investigating the new insights linking HF with cancer is rapidly becoming an exciting new field of research, and we herein review the most recent data. Besides insights in mechanisms, we call for clinical awareness, that is essential to optimize treatment strategies of patients having developed cancer with a history of HF. Finally, ongoing and future trials should strive for comprehensive phenotyping of both CV and cancer end points, to allow optimal usefulness of data, and to better describe and understand common characteristics of these two lethal diseases.

Mortality in Spain in the Context of the Economic Crisis and Austerity Policies

Objectives. To analyze the mortality trend in Spain before, during, and after the economic crisis and austerity policies. Methods. We calculated age-standardized annual mortality rates in 2001 through 2016 and estimated linear trends in mortality rates during 4 periods (2001-2007, 2008-2010, 2011-2013, and 2014-2016) using the annual percentage change (APC). Results. All-cause mortality rate decreased during the period 2001 to 2016, although we found increases over the previous year. After adjusting for increased influenza activity (P = .743) and heat waves (P = .473), we found the greatest declines during the economic crisis (2008-2010) and the smallest in the period 2014 to 2016, in which the APC in mortality rates was -2.9 and -0.6, respectively. The APC before the crisis (2001-2007) and during austerity (2011-2013) was -2.0 and -2.2, respectively. We observed similar results in mortality from cardiovascular, respiratory, and digestive diseases and motor vehicle accidents. Mortality from cancer showed the smallest decline during the crisis and the austerity period, whereas suicide increased in the period 2011 to 2013. Conclusions. Lifestyle changes could explain the decline in mortality during the economic crisis. Increased influenza activity and the 2015 heat wave may prevent identifying a possible delayed effect of austerity policies in the slowing down of mortality decline in the period 2014 to 2016.

Association between plasma lipid levels during acute coronary syndrome and long-term malignancy risk. The ABC-4* study on heart disease

Background

Emerging evidence suggests that patients with coronary artery disease carry an increased risk of developing malignancy, with deleterious effects on long-term prognosis. Our aim was to ascertain whether baseline plasma lipid levels during acute coronary syndrome (ACS) are associated with malignancy in long-term.

Methods

This study included 589 patients admitted with ACS to three centers and discharged alive. Plasma lipid levels were assessed on the first morning after admission. Patients were followed for 17 years or until death.

Results

Five hundred seventy-one patients were free from malignancy at enrollment, of them 99 (17.3%) developed the disease during follow-up and 75 (13.1%) died due to it. Compared to patients without malignancy, those with malignancy showed lower plasma levels of total cholesterol (TC), low-density lipoprotein (LDL), and triglycerides (TG). The groups showed similar statin use rates at any time in follow-up. The incidence rate of neoplasia and neoplastic mortality was higher in patients with baseline TC or LDL values ≤ median; they showed 85 and 72% increased incidence rate of developing malignancy and 133 and 122% increased incidence rate of neoplastic death respectively. No differences were observed relative to HDL and TG levels. In survival analysis using Cox regression with parsimonious models, patients with baseline TC or LDL values > median, respectively, showed risks of 0.6(95% CI 0.4–0.9; p = 0.01) and 0.6(95%CI 0.4–0.9; p = 0.02) for malignancy onset, and 0.5(95% CI 0.3–0.8; p = 0.005) and 0.5(95% CI 0.3–0.8; p = 0.004) for neoplastic death. Similar results were obtained using competitive risk analysis with parsimonious models.

Conclusions

This long-term prospective study of an unselected real-world patient sample showed that neoplasia onset and mortality are independently associated with low plasma TC and LDL levels at admission for ACS.

Common risk factors for heart failure and cancer

Cardiovascular (CV) disease and cancer are the leading causes of death.1,2 Over the last decades, it has been appreciated that both CV disease and cancer are more common in individuals in whom risk factors for disease development accumulate, and preventative measures have been extremely important in driving down the incidence of disease.3-6 In general, the field of epidemiology, risk reduction, and preventative trials is divided into health care professionals who have an interest in either CV disease or cancer. As a result, the medical literature and medical practice has largely focused on the one disease, or the other. However, human individuals do not behave according to this dogma. Emerging data clearly suggest that identical risk factors may lead to CV disease in the one individual, but may cause cancer in another, or even both diseases in the same individual. This overlap exists between risk factors that are historically classified as 'CV risk factors' as these factors do equally strong predict cancer development. Therefore, we propose that a holistic approach might better estimate actual risks for CV disease and cancer. In this review, we summarize current insights in common behavioural risk factors for heart failure, being the most progressed and lethal form of CV disease, and cancer.

Competing Risk of Death in Elderly Patients with Newly Diagnosed Stage I Breast Cancer

BACKGROUND

The majority of newly diagnosed breast cancers in the US are in women aged older than 65 years who can have additional comorbidities. Balancing the risks and benefits of treatment should take into account these competing risks of death.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results Program-Medicare database was used to identify women with stage I breast cancer undergoing operations from 2004-2012. Using neural network analysis, comorbidities associated with mortality were grouped into clinically relevant categories. Cumulative incidence graphs and Fine and Gray competing risk regression analyses were used to study the association of age, race, comorbidity groupings, and tumor variables with 3 competing mortality outcomes: dead of disease (DOD), dead of other cancers (DOC), and non-cancer death (NCD).

RESULTS

The overall cumulative incidence of mortality was 4.9% for DOD, 3.7% for DOC, and 21.3% for NCD for the 47,220 patients studied. For all patients, the 5- and 8-year probability of DOD was 3% and 4.7%, for DOC 1.9% and 3.5%, and for NCD 9.8% and 18.9%, respectively. The presence of any major comorbidity (eg cardiovascular or neurologic disorders) significantly increased the probability of NCD, and estrogen receptor status was the strongest predictor of DOD. Given patient age, comorbidity, and estrogen receptor status, an estimate of competing risks of death from DOD, DOC, and NCD can be calculated.

CONCLUSIONS

To aid clinical decision making, we quantify competing risks of death in patients with stage I breast cancer by taking into account patient age, comorbidity, and estrogen receptor status.

Macroeconomic fluctuations, changes in lifestyles and mortality from diabetes: a quasiexperimental study

BACKGROUND

To evaluate trends in diabetes-related health behaviours and mortality from diabetes and other chronic diseases in the Spanish population before, during and after the 2008 economic crisis.

METHODS

Annual population measurements were obtained from national surveys and administrative registries for 2004-2016. Using segmented regression analysis, we calculated the annual percentage change (APC) in 2004-2007, 2008-2010, 2011-2013 and 2014-2016 in risk behaviours (smoking, alcohol consumption, obesity and meals away from home), in healthy behaviours (fruit and vegetable intake and physical activity) and in mortality rates from diabetes, cardiovascular disease and cancer.

RESULTS

In general, during the economic crisis (2008-2013), the Spanish population reduced risk behaviours and improved healthy behaviours as compared with the trend observed before and afterwards. Diabetes mortality decreased more during the crisis than before or afterwards. The APC in each time interval was -3.3, -3.7, -4.4 and -2.6 in all-age mortality and -2.9, -5.2, -6.7 and -1.3 in premature mortality (less than 75 years). Only in older people (≥75 years) diabetes mortality showed similar decline before and during the crisis. Mortality from cardiovascular disease also declined more during the crisis, except for all-age mortality and older people in the second part of the crisis, whereas the downward trend in cancer mortality was smaller during the crisis years.

CONCLUSIONS

During the 6 years of the economic crisis in Spain, the favourable changes in health behaviours were accompanied by an important reduction in diabetes mortality in the population.

Obesity and cardiovascular risk in an oncology day ward population

INTRODUCTION

The burden of obesity and risk of cardiovascular (CV) disease amongst an oncology population receiving active treatment is ill-defined. We performed a retrospective analysis assessing the incidence of obesity and cardiovascular (CV) risk factors in this group (grp) of patients as well as the predicted 10-year risk of a CV event.

METHODS

Data from all patients (pts) receiving intravenous chemotherapy in an Irish oncology satellite unit over an 18-month period was extracted from chemotherapy prescriptions and electronic patient records. To calculate patients' 10-year risk of developing CV disease, we used QRISK, a predictive risk calculator.

RESULTS

The prevalence of obesity (BMI > 30) amongst the total population was 19% (n = 21), with 26% (n = 28) overweight (BMI, 25-< 30). Information on CV risk factors was available in 93 pts. with the following rates being observed: hypertension 34%, dyslipidaemia 19%, current smoker 18% and diabetes 11%. The average 10-year risk of a CV event (stroke/MI) in this cohort was 19.2% (± 16.6), with a relative risk of 1.4 compared to their age-matched controls without CV risk factors.

CONCLUSIONS

We observed similar or lower rates of obesity and CV risk factors in this cohort compared to the general adult Irish population. The average predicted risk of developing CV disease in this grp was moderate to high. This can have significant future implications with regard to cancer survivorship, disease recurrence and suitability for further oncological treatments.

Serum glucose, triglycerides, and cholesterol in relation to prostate cancer death in the Swedish AMORIS study

PURPOSE

Lifestyle-related conditions such as obesity are associated with prostate cancer progression, but the associations with hyperglycemia and dyslipidemia are unclear. This study, therefore, aims to examine the association of glucose, triglycerides, and total cholesterol with prostate cancer death.

METHODS

From the Swedish AMORIS cohort, we selected 14,150 men diagnosed with prostate cancer between 1996 and 2011 who had prediagnostic measurements of serum glucose, triglycerides, and total cholesterol. Multivariable Cox proportional hazards regression models were used to determine the hazard ratios for death in relation to the aforementioned metabolic markers.

RESULTS

Using clinical cut-off points, a non-significant positive association was observed between glucose and prostate cancer death. When compared to those with glucose in the lowest quartile, those in the highest quartile had greater risk of prostate cancer death (HR 1.19; 95% CI 1.02-1.39). However, neither total cholesterol nor triglycerides were associated with prostate cancer death. Glucose and triglycerides were positively associated with overall, cardiovascular, and other deaths. Hypercholesterolemia was only associated with risk of CVD death.

CONCLUSION

Our results suggest that glucose levels may influence prostate cancer survival, but further studies using repeated measurements are needed to further elucidate how glucose levels may influence prostate cancer progression.

The mortality reducing effect of aspirin in colorectal cancer patients: Interpreting the evidence

In 1971 the first study appeared that suggested a relationship between aspirin and cancer. Currently publications on the subject of aspirin and cancer are numerous, with both a beneficial effect of aspirin on cancer incidence and a beneficial effect on cancer survival. This review focusses on the relation between the use of aspirin and improved survival in colorectal cancer patients. Various study designs have been used, with the main part being observational studies and post hoc meta-analyses of cancer outcomes in cardiovascular prevention trials. The results of these studies are unambiguously pointing towards an effect of aspirin on colorectal cancer survival, and several randomised controlled trials are currently ongoing. Some clinicians feel that the current evidence is conclusive and that the time has come for aspirin to be prescribed as adjuvant therapy. However, until this review, not much attention has been paid to the specific types of bias associated with these studies. One of these biases is confounding by indication, because aspirin is indicated for patients as secondary prevention for cardiovascular disease. This review aims to provide perspective on these biases and provide tools for the interpretation of the current evidence. Albeit promising, the current evidence is not sufficient to already prescribe aspirin as adjuvant therapy for colorectal cancer.

Patterns of statin initiation and continuation in patients with breast or colorectal cancer, towards end-of-life

Purpose

Cross-sectional studies show that statins, used in cardiovascular disease prevention, are often discontinued approaching death. Studies investigating associations between statin exposure and cancer outcomes, not accounting for these exposure changes, are prone to reverse causation bias. The aim of this study was to describe longitudinally the changes in statin initiation and continuation prior to death in patients with breast or colorectal cancer, thus establishing an appropriate exposure lag time.

Methods

This study was carried out using linked cancer registry and prescribing data. We identified patients who died of their cancer (cases) and cancer survivors were used as controls. The probability of initiating or continuing statin use was estimated up to 5 years prior to death (or index date). Conditional binomial models were used to estimate relative risks and risk differences for associations between approaching cancer death and statin use.

Results

Compared to controls, the probability of continued statin use in breast cancer cases was significantly lower 3 months prior to death (RR 0.86 95% CI 0.79, 0.94). Similarly, in colorectal cancer cases, the probability of continued statin use was significantly lower 3 months prior to colorectal cancer death (RR 0.77 95% CI 0.68, 0.88).

Conclusion

A significant proportion of patients will cease statin treatment in the months prior to a colorectal or breast cancer death.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-017-3576-0) contains supplementary material, which is available to authorized users.