Increasing risks of ischemic stroke in oral cancer patients treated with radiotherapy or chemotherapy: a nationwide cohort study

Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Risk of cerebrovascular disease after cancer diagnosis in the United States

The risk of subsequent cerebrovascular disease among cancer patients of multiple cancers in the US is not well understood. A total of 3,843,261 cancer patients diagnosed from 1975 to 2018, were included from the surveillance, epidemiology, and end results (SEER) database. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) were estimated. The overall cerebrovascular disease SMR was 1.04 (95% CI, 1.03-1.04), and the AER per 10,000 person-years at risk was 0.89. When compared with the US general population, greater cerebrovascular disease risk was correlated with certain cancer sites, American Indian/Alaska Native race, Asian or Pacific Islander race, unmarried marital status, distant metastasis, younger age, and an earlier time of cancer diagnosis. Clinically, more precision and proactive strategies for cerebrovascular disease prevention are required to subgroup of cancer patients with a greater risk of cerebrovascular disease, especially within the first two months.

The Risk of Ischemic and Hemorrhagic Stroke in Head and Neck Cancer: A Longitudinal Cohort Study

Several studies have shown that head and neck cancer is associated with an increased risk of stroke incidence. However, investigations of the association between the two diseases based on a matching cohort dataset are still limited. Therefore, we identified the incidence and risk of stroke in patients with head and neck cancer using a nationwide population-based cohort dataset. A total of 5248 individuals without cancer and 1312 with cancer were enrolled from the dataset after a 4:1 propensity score matching. We found that the incidence of overall stroke (per 1000 person years) was 19.29 for those with head and neck cancer, consisting of 17.32 as ischemic type and 2.74 as hemorrhagic type. Additionally, patients with head and neck cancer had a significantly increased risk of overall and ischemic stroke development but not hemorrhagic stroke. Moreover, the risk of stroke development over time was relatively high within the first year after the diagnosis of head and neck cancer. However, in the subgroup analysis, oral cavity cancer survivors showed an increased risk of both ischemic and hemorrhagic strokes. Therefore, our nationwide population-based cohort study suggests that clinicians should closely monitor patients with head and neck cancers for the early detection of stroke.

Is stroke incidence increased in survivors of adult cancers? A systematic review and meta-analysis

PURPOSE

Existing research hints that people living with and beyond cancer are at an increased risk of stroke. However, there is insufficient evidence to appropriately inform guidelines for specific stroke prevention or management for cancer patients. We conducted a systematic review and meta-analysis to describe and quantify stroke incidence in people living with and beyond cancer.

METHODS

Medline, CINAHL, and EMBASE were searched for epidemiological studies comparing stroke incidence between cancer and non-cancer patients. Reviewers independently extracted data; random-effects meta-analyses and quality assessment were performed.

RESULTS

Thirty-six studies were narratively synthesised. Meta-analysis was conducted using seven studies. Methodological quality was high for most studies. Study populations were heterogeneous, and the length of follow-up and risk factors varied. There was a variation in risk between different cancer types and according to stroke type: pancreatic (HR 2.85 (95% CI 2.43-3.36), ischaemic) (HR 2.28 (95% CI 1.43-3.63), haemorrhagic); lung (HR 2.33 (95% CI 1.63-3.35), ischaemic) (HR 2.14 (95% CI 1.45-3.15), haemorrhagic); and head and neck (HR 1.54 (95% CI 1.40-1.69), haemorrhagic) cancers were associated with significantly increased incidence of stroke. Risk is highest within the first 6 months of diagnosis. Narrative synthesis indicated that several studies also showed significantly increased incidence of stroke in individuals with colorectal cancer, breast cancer, ovarian cancer, nasopharyngeal cancer, leukaemia, and myeloma, and those who have received radiotherapy for head and neck cancers and platinum-based chemotherapy may also have higher stroke incidence.

CONCLUSIONS

Stroke incidence is significantly increased after diagnosis of certain cancers.

IMPLICATIONS FOR CANCER SURVIVORS

Cardiovascular risk should be assessed during cancer survivorship care, with attention to modifying shared cancer/cardiovascular risk factors.

The Link between Stroke Risk and Orodental Status-A Comprehensive Review

One of the primary causes of disability and mortality in the adult population worldwide is stroke. A person's general health is significantly impacted by their oral and dental health. People who have poor oral health are more susceptible to conditions such as stroke. Stroke risk has long been linked to oral and dental conditions. The risk of stroke and its cost impact on the healthcare systems appear to be significantly reduced as a result of the decline in the incidence and prevalence of oral and dental illnesses. Hypothetically, better management of oral hygiene and dental health lead to reduced stroke risk. To the authors' best knowledge, for the first time, the potential link between dental health and stroke were cross-examined. The most typical stroke symptoms, oral and dental illnesses linked to stroke, and the role of oral healthcare professionals in stroke prevention are revealed. The potential mediating processes and subsequent long-term cognitive and functional neurological outcomes are based on the available literature. It must be noted that periodontal diseases and tooth loss are two common oral health measures. Lack of knowledge on the effects of poor oral health on systemic health together with limited access to primary medical or dental care are considered to be partially responsible for the elevated risk of stroke. Concrete evidence confirming the associations between oral inflammatory conditions and stroke in large cohort prospective studies, stratifying association between oral disease severity and stroke risk and disease effects on stroke survival will be desirable. In terms of clinical pathology, a predictive model of stroke as a function of oral health status, and biomarkers of systemic inflammation could be useful for both cardiologists and dentists.

The Risk of Ischemic Stroke in Head and Neck Cancer Patients and Those Who Were Treated with Radiotherapy: A Population-Based Cohort Study

BACKGROUND

To investigate the standardized incidence ratios (SIR) of stroke in patients with head and neck cancer and their relationship to radiotherapy.

METHODS

Patients with head and neck cancer ages 20-85 years were enrolled from 2007 to 2016 using the Taiwan Cancer Registry. The study endpoint was fatal and non-fatal ischemic stroke, ascertained by the National Health Insurance Research Database. Age- and sex-adjusted SIRs, categorized by 10-year age standardization, were used to compare the patients with head and neck cancer with a randomly selected 2,000,000 general population. We compared the risk of stroke in patients with head and neck cancer who received radiotherapy or surgery alone. Multivariable adjusted hazard ratios (HR) and 95% confidence intervals (CI) were obtained from Cox regression analysis with competing risk.

RESULTS

Among 41,266 patients (mean age, 54.1 years; men, 90.6%) in the median follow-up period of 3.9 years, 1,407 strokes occurred. Compared with the general population, the overall SIR of stroke was 1.37 (95% CI, 1.30-1.44) in patients with head and neck cancer. In patients with head and neck cancer, the fully adjusted HR of stroke in those who received radiotherapy was 0.96 (95% CI, 0.83-1.10), compared with those who received surgery alone.

CONCLUSIONS

Patients with head and neck cancer had a higher risk of fatal or non-fatal ischemic stroke. The risk of stroke was not higher in patients initially treated with radiotherapy.

IMPACT

Oncologists should emphasize stroke prevention in all patients with head and neck cancer, not only in those who received radiotherapy.

Risk of Stroke in Nasopharyngeal Cancer Survivors: A National Registry-Based Population Cohort Study

BackgroundWe aim to determine the risk of stroke and death within 30 days post stroke in nasopharyngeal cancer (NPC) survivors.MethodsWe conducted a population-based cohort study of patients diagnosed with NPC from Jan 1, 2005 to Dec 31, 2017. Using the cancer and stroke disease registries and the Singapore general population as the reference population, we report the age-standardized incidence rate differences (SIRDs) ratios (SIRs) and the cumulative incidence of stroke and the standardized mortality rate differences (SMRDs) and ratios (SMRs) for all causes of death within 30 days post stroke for NPC survivors.FindingsAt a median follow up of 48.4 months (IQR 19.8 - 92.9) for 3849 patients diagnosed with NPC, 96 patients developed stroke. The overall SIRD and SIR for stroke was 3.12 (95% CI 2.09 - 4.15) and 2.54 (95% CI 2.08 - 3.10) respectively. The SIRD was highest for the age group 70 - 79 years old (8.84 cases per 1000 person-years (PY); 0.46 - 17.21) while the SIR was highest for the age group 30 - 39 years old (16.41; 6.01 - 35.82). The SIRD and SIR for stage 1 disease was (6.96 cases per 1000 PY; 2.16 - 11.77) and (4.15; 2.46 - 7.00) respectively. The SMRD and SMR for all cause deaths within 30 days of stroke was (3.20 cases per 100 persons; -3.87 - 10.28) and (1.34; 0.76 - 2.37) respectively.InterpretationThe overall risk of stroke was markedly elevated in survivors of NPC, especially in Stage 1 disease when compared to the general population. The risk of death within 30 days of stroke was not significantly higher for NPC survivors.Classification of EvidenceThis study provides Class II evidence of the increased risk of stroke in survivors of nasopharyngeal cancer compared to general population.

Use of Intravenous Thrombolysis in Acute Ischemic Stroke Management in Patients with Active Malignancies: A Topical Review

OBJECTIVES

Our review aims to present existing data on the safety of Intravenous thrombolysis (IVT) use in acute ischemic stroke (AIS) patients with concomitant central nervous system or systemic malignancies, with attention to special circumstances pertaining to specific cancer subtypes to help in acute decision making, especially for neurologists and emergency medicine physicians.

METHODS

A literature search was conducted on electronic databases inclusive of Medline, EMBASE and CINAHL for articles published or available in English between January 1, 2000 to June 1, 2020 using the following search terms: "acute ischemic stroke," "cerebrovascular disease," "Intravenous thrombolysis," "tissue plasminogen activator," "cancer patients," and "neoplasm".

CONCLUSION

Recognition of stroke symptoms in patients with active cancer, in particularly those involving the brain, requires astute clinical judgement. Decision-making can be improved by understanding baseline functional status, cancer prognosis and expected disability from stroke, as well as utilizing diagnostic modalities such acute MRI where needed. While this article does not encourage use of IVT in patients with all malignancies, it lays the groundwork for decision making should thrombolysis be a consideration in a patient with AIS in a cancer patient.

Risk of Stroke in Cancer Survivors: A Meta-analysis of Population-Based Cohort Studies

OBJECTIVE

Accumulating evidence suggests that cancer survivors may have a relatively higher risk of stroke. The aim of this meta-analysis was to determine whether cancer survivors have a relatively higher risk of stroke than cancer-free populations on the basis of published data from population-based cohort studies.

METHODS

PubMed, Embase, and Cochrane Library were searched from inception to February 8, 2020, for population-based cohort studies. Effect estimates with 95% confidence intervals (CIs) were pooled using the random-effects model. We conducted subgroup analyses and meta-regression to explore sources of heterogeneity and the stability of the results.

RESULTS

Twenty population-based cohort studies involving 10,479,530 participants were identified. Overall, the relative risk (RR) for stroke in cancer survivors was 1.66 (95% CI 1.35-2.04; p < 0.001) compared with that in cancer-free controls; survivors of head and neck, hematologic, lung, pancreas, and stomach cancer (all p < 0.05) showed consistently significant results, whereas no significant increased risk was observed for patients with other cancer types. The effects were more prominent in cancer survivors with female sex (RR 1.38, 95% CI 1.18-1.61; p < 0.001), younger age at cancer diagnosis (<45 years) (RR 2.57, 95% CI 1.27-5.19; p = 0.009), and shorter cancer survival duration (≥1-2 years) (RR 1.69, 95% CI 1.18-2.42; p = 0.004). Moreover, cancer survivors had a significantly increased risk of ischemic stroke (RR 1.53, 95% CI 1.28-1.84; p < 0.001) compared with hemorrhagic stroke.

CONCLUSIONS

Cancer plays a critical role in the etiologic of stroke. Due to the existence of substantial heterogeneity among the included studies, the results should be interpreted with caution. However, early prevention and effective intervention of stroke in cancer survivors require attention from health policy makers.

Radiotherapy Exposure in Cancer Patients and Subsequent Risk of Stroke: A Systematic Review and Meta-Analysis

Background: Cancer patients who have undergone radiotherapy may have an increased risk of subsequent stroke. A clear and detailed understanding of this risk has not been established. Methods: A search for research articles published from January 1990 to November 2017 in the English language was conducted. Subsequent stroke risk in cancer survivors was compared using relative risk (RR) and 95% confidence intervals (CI) according to whether or not radiotherapy was given. Results: A total of 12 eligible studies were identified including 57,881 total patients. All studies were retrospective, as no prospective studies were identified. The meta-analysis revealed a higher overall risk of subsequent stroke in cancer survivors/patients given radiotherapy compared to those not given radiotherapy (RR: 2.09, 95% CI: 1.45, 3.16). In addition, compared to patients not given radiotherapy, there was an increased risk of subsequent stroke for radiotherapy treated patients with Hodgkin's lymphoma (RR: 2.81, 95% CI: 0.69, 4.93) or head/neck/brain/nasopharyngeal cancer (RR: 2.16, 95% CI: 1.16, 3.16), for patients younger than 40 years (RR: 3.53, 95% CI: 2.51, 4.97) or aged 40-49 years (RR: 1.23, 95% CI: 1.09, 1.45) and for patients treated in Asia (RR: 1.88, 95% CI: 1.48, 2.29), the United States (RR: 1.62, 95% CI: 1.01, 2.23), or in Europe (RR: 4.11, 95% CI 2.62, 6.45). Conclusions: The available literature indicates an approximate overall doubling of the subsequent stroke risk in cancer patients given radiotherapy. The elevated risk was generally statistically significant according to cancer type, baseline patient age and region or country where treatment was given. Caution is required in interpreting these findings due to the heterogeneity of populations represented and lack of standardization and completeness across published studies. Further, if real, we cannot conclude the extent to which patient, treatment and/or investigational factors are responsible for this apparent elevated risk. An objective and more detailed understanding of the risks of radiotherapy, and how to prevent them, is urgently required. It is the responsibility of all who provide cancer services to ensure that the experience of all their patients is documented and analyzed using quality registries.

Risk of Stroke After Colorectal Surgery for Cancerous Versus Benign Conditions

BACKGROUND

Cancer treatment, specifically surgical intervention, as a possible stroke trigger is understudied.

METHODS

Using the Nationwide Readmissions Database and validated diagnosis and procedure codes, we identified adults with index admissions for colorectal surgery for colorectal adenocarcinoma (Group A) and compared them to admissions for colorectal surgery for benign conditions (Group B) and hepatobiliary or pancreatic surgery for benign conditions (Group C). Within the colorectal cancer cohort, we further identified patients who underwent open versus laparoscopic surgery. The primary outcome was readmission for ischemic or hemorrhagic stroke up to 1 year. Cumulative risk of ischemic stroke was calculated using risk survival statistics, and hazard ratios (HR) were calculated using adjusted Cox regression.

RESULTS

Patients in Group A had higher 3-month readmission rates for ischemic and hemorrhagic strokes than those in Groups B and C. Higher risk of ischemic stroke (HR 1.46, 95% confidence interval [CI] 1.20-1.79) in Group A compared to Group B was eliminated following adjustments for illness severity and vascular risk factors. Comparing types of colorectal surgical intervention for cancer, there was significantly greater risk of ischemic stroke with open versus laparoscopic surgery, despite adjusting for vascular risk factors (HR 1.70, 95% CI 1.15-2.52).

CONCLUSIONS

We found elevated risk of ischemic stroke up to 1 year following open surgery for colorectal adenocarcinoma compared to laparoscopic. More research is necessary to clarify the underlying surgery-related mechanisms that contribute to elevated risk.

Evaluating the Primary Prevention of Ischemic Stroke of Oral Antithrombotic Therapy in Head and Neck Cancer Patients with Radiation Therapy

Although previous studies demonstrated the risk of ischemic stroke (IS) in patients with head and neck cancer (HNC), the impact of oral antithrombotic therapy (OAT) on this risk has not yet been assessed. We aimed to evaluate the effectiveness and safety of OAT in patients with HNC treated with RT. This retrospective cohort study was performed using the National Health Insurance Research Database of Taiwan. A total of 37,638 patients diagnosed with HNC included in the study were classified as users and nonusers of OAT. Primary outcome was IS or transient ischemic attack (TIA), and secondary outcomes were death and major bleeding. The Cox proportional hazards model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). There was no significant difference in the risk of IS or TIA between patients on continuous OAT and nonusers (adjusted HR, 0.812; 95% CI, 0.199-3.309). The risk of major bleeding was not significantly different between the groups. From a national population database, we did not find an association between OAT and decreasing risk of ischemic stroke/TIA or increasing hazard of major bleeding.