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Moon J, Rhyu JM, Jeong C, Lee SJ, Kim JS, Kang HG. Risk of ischemic stroke in korean patients with Cancer: Insights from national health insurance data. J Stroke Cerebrovasc Dis 2025; 34:108281. [PMID: 40058679 DOI: 10.1016/j.jstrokecerebrovasdis.2025.108281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 03/05/2025] [Accepted: 03/06/2025] [Indexed: 03/30/2025] Open
Abstract
OBJECTIVES This study aimed to compare the cumulative incidence of ischemic stroke between patients with and without cancer, estimate the hazard ratio of stroke in patients with cancer compared to those without cancer, and compare our results with those of other nationwide studies. MATERIALS AND METHODS We recruited 91,424 patients diagnosed with cancer from the Korean National Health Insurance Service database between 2011 and 2015 and enrolled 182,848 controls. These participants were followed up for 5 years. We estimated the hazard ratios for ischemic stroke occurrence in the patient groups for all cancer types and nine specific cancer types during follow-up at 6 months and 1, 3, and 5 years. RESULTS For all cancer types, except colorectal, gallbladder, bile duct, and head and neck cancers, the slope of the cumulative increase in ischemic stroke in the early period was higher than that in longer follow-up durations. Ischemic stroke risk was elevated after the 6-month follow-up in patients with cancer compared to patients without cancer (95% confidence interval [CI]: 1.56-1.94). Over 3-5 years, Ischemic stroke risk increased in patients with lung (CI: 1.56-2.04), pancreatic (CI: 1.33-1.95), and liver cancers (CI: 1.07-1.39), compared to cancer-free individuals, whereas no significant increase was observed in patients with thyroid (CI: 0.79-1.13), stomach (CI: 0.92-1.17), colorectal (CI: 0.69-1.48), gallbladder (CI: 0.91-9.89), bile duct (CI: 0.39-3.50), and head and neck (CI: 0.26-74.30) cancers. CONCLUSION Our findings regarding stomach, colorectal, and liver cancers differ from the results of Western studies. Conducting a nationwide study within each country, rather than applying findings from other countries, is preferable for predicting and preventing ischemic stroke development in patients with cancer when using insurance-based data.
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Affiliation(s)
- Juwang Moon
- Jeonbuk National University Medical School, Jeonju, South Korea.
| | - Ji Min Rhyu
- Department of Neurology and Research Institute of Clinical Medicine of Jeonbuk National University Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
| | - Choyun Jeong
- Department of Medical Informatics, Jeonbuk National University Medical School, Jeonju, South Korea.
| | - Seung Jae Lee
- Department of Chemistry, Institute of Molecular Biology and Genetics, Jeonbuk National University, Jeonju 54907, South Korea.
| | - Jong Seung Kim
- Department of Medical Informatics, Jeonbuk National University Medical School, Jeonju, South Korea; Department of Otorhinolaryngology and Research Institute of Clinical Medicine of Jeonbuk National University Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
| | - Hyun Goo Kang
- Department of Neurology and Research Institute of Clinical Medicine of Jeonbuk National University Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
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Jiang JL, Chang JTC, Huang BS, Chang TY, Sung PS, Wei YC, Lin CY, Yeh CH, Fan KH, Liu CH. Post-irradiation vertebral and carotid stenosis heightens stroke risk in head and neck cancer. BMC Cancer 2025; 25:235. [PMID: 39934712 DOI: 10.1186/s12885-025-13647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 02/04/2025] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND The relative risk of ischemic stroke (IS) in head and neck cancer (HNC) patients developing carotid artery stenosis (CAS) or vertebral artery stenosis (VAS) after radiation therapy (RT) remains uncertain due to limited studies, complicating vascular follow-ups and preventive strategies. METHODS We included HNC patients who received RT between 2010 and 2023. The patients were divided into nasopharyngeal carcinoma (NPC) and non-NPC groups. The primary outcome was the occurrence of IS after RT, and the secondary outcomes included the development of > 50% CAS or > 50% VAS after RT. RESULTS Of the 1,423 HNC patients, there were 19% of patients developed > 50% CAS, 6.8% of patients developed > 50% VAS, and 2.3% of patients developed IS. In patients with HNC, > 50% CAS (adjusted hazard ratio [HR] = 3.21, 95% confidence interval [CI] = 1.53-6.71), and > 50% VAS (adjusted HR = 2.89, 95% CI = 1.28-6.53) were both the independent predictors of IS. In the patients with NPC, > 50% CAS was an independent predictor of anterior circulation IS (adjusted HR = 4.39, 95% CI = 1.17-16.47). By contrast, > 50% VAS emerged as a predictor of posterior circulation IS in both the NPC (adjusted HR = 15.02, 95% CI = 3.76-60.06) and non-NPC groups (adjusted HR = 13.59, 95% CI = 2.21-83.46). CONCLUSION HNC patients with > 50% CAS or > 50% VAS after RT had an increased risk of IS within their corresponding vascular territory. CAS could be an important predictor of IS in NPC patients, whereas VAS might also be a significant predictor of IS in both NPC and non-NPC patients. Evaluation both the carotid and vertebral arteries after RT might be necessary. TRIAL REGISTRATION ClinicalTrials.gov identifier No.: NCT06111430.
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Grants
- CMRPG3M0811, CMRPG381503, CMRPG3C0763, CMRPG3G0261, CFRPG3L0011, and BMRPF99 Chang Gung Memorial Hospital
- 106-2511-S-182A-002-MY2, 108-2314-B-182A-050-MY3, 111-2314-B-182A-133-MY3, 113-2314-B-182A-114-MY3NMRPG3M6231-3, NMRPG3G6411-2, and NMRPG3J6131-3 he National Science and Technology Council of Taiwan
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Affiliation(s)
- Jian-Lin Jiang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Joseph Tung-Chieh Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Bing-Shen Huang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Ting-Yu Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chia Wei
- Department of Neurology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Yu Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Taipei Chang Gung Head & Neck Oncology Group, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
- Radiation Research Core Laboratory, Chang Gung University/ Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Chih-Hua Yeh
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neuroradiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Kang-Hsing Fan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Radiation Oncology, New Taipei Municipal Tu-Cheng Hospital, New Taipei City, Taiwan
| | - Chi-Hung Liu
- Stroke Center and Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Tsai YT, Tsai MH, Kudva A, Vito AD, Lai CH, Liao CT, Kang CJ, Tsai YH, Hsu CM, Huang EI, Chang GH, Tsai MS, Fang KH. The Prognostic Value of Preoperative Total Cholesterol in Surgically Treated Oral Cavity Cancer. Biomedicines 2024; 12:2898. [PMID: 39767804 PMCID: PMC11726739 DOI: 10.3390/biomedicines12122898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 12/17/2024] [Accepted: 12/18/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND With growing evidence linking lipid profile changes to tumor development and cancer prognosis, we investigated the prognostic significance of preoperative serum total cholesterol (TC) levels in patients with oral cavity squamous cell carcinoma (OSCC) undergoing surgical treatment. METHODS We conducted a retrospective observational study involving 310 patients with primary OSCC who received surgery at our hospital from January 2009 to December 2018. Receiver operating characteristic curve analysis was performed to determine the optimal preoperative TC cutoff value, with the Youden Index employed as the optimization criterion to maximize the sum of sensitivity and specificity. Variables with p < 0.1 in the univariable analysis were included in the multivariable Cox regression model, and stepwise selection was used to identify the optimal subset of prognostic factors for overall survival (OS) and disease-free survival (DFS). RESULTS An optimal TC cutoff of 157 mg/dL was established. Patients with TC < 157 mg/dL exhibited significantly lower 5-year rates of OS and DFS (p < 0.001 and p = 0.006, respectively). Multivariable analysis confirmed that TC < 157 mg/dL represented an independent prognostic factor for reduced OS and DFS rates. Subgroup analyses reinforced the consistent prognostic significance of TC. We also constructed a nomogram (concordance index: 0.74) to provide personalized OS predictions, enhancing the clinical utility of TC. CONCLUSIONS Preoperative TC appears to be a significant prognostic factor for OS and DFS after OSCC surgery. Routine TC assessment facilitates the development of nomograms for personalized survival predictions, supports clinicians in tailoring treatment strategies, and guides nutritional or metabolic interventions to enhance patient outcomes. Further multicenter prospective studies are needed to validate our findings.
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Affiliation(s)
- Yao-Te Tsai
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (Y.-T.T.); (C.-M.H.); (E.I.H.); (G.-H.C.); (M.-S.T.)
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
| | - Ming-Hsien Tsai
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Adarsh Kudva
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Andrea De Vito
- Ear Nose Throat (ENT) Unit, Department of Surgery, Forli Hospital Health Local Agency of Romagna, 47121 Forli, Italy;
| | - Chia-Hsuan Lai
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
| | - Chun-Ta Liao
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 333423, Taiwan
| | - Chung-Jan Kang
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 333423, Taiwan
| | - Yuan-Hsiung Tsai
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
| | - Cheng-Ming Hsu
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (Y.-T.T.); (C.-M.H.); (E.I.H.); (G.-H.C.); (M.-S.T.)
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
| | - Ethan I. Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (Y.-T.T.); (C.-M.H.); (E.I.H.); (G.-H.C.); (M.-S.T.)
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
| | - Geng-He Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (Y.-T.T.); (C.-M.H.); (E.I.H.); (G.-H.C.); (M.-S.T.)
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
| | - Ming-Shao Tsai
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan; (Y.-T.T.); (C.-M.H.); (E.I.H.); (G.-H.C.); (M.-S.T.)
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
| | - Ku-Hao Fang
- College of Medicine, Chang Gung University, Taoyuan 330036, Taiwan; (M.-H.T.); (C.-H.L.); (C.-T.L.); (C.-J.K.); (Y.-H.T.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan 333423, Taiwan
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Yip PL, Zheng H, Cheo T, Tan TH, Lee SF, Leong YH, Wong LC, Tey J, Ho F, Soon YY. Stroke Risk in Survivors of Head and Neck Cancer. JAMA Netw Open 2024; 7:e2354947. [PMID: 38349657 PMCID: PMC10865145 DOI: 10.1001/jamanetworkopen.2023.54947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 12/13/2023] [Indexed: 02/15/2024] Open
Abstract
Importance Survivors of head and neck cancers (HNC) have increased risk of stroke. A comprehensive report using standardized methods is warranted to characterize the risk and to inform on survivorship strategy. Objective To determine the stroke risk in subpopulations of survivors of HNC in Singapore. Design, Setting, and Participants This national, registry-based, cross-sectional study aimed to estimate stroke risk in subgroups of the HNC population between January 2005 and December 2020. Participants were identified from the Singapore Cancer Registry, the Singapore Stroke Registry, and the Registry of Birth and Deaths using relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes. HNC subgroups were defined based on patient demographic, disease, and treatment factors. Data were analyzed from September 2022 to September 2023. Exposure Diagnosis of HNC. Main Outcomes and Measures Both ischemic and hemorrhagic stroke were studied. The age-standardized incidence rate ratio (SIRR) and age-standardized incidence rate difference (SIRD) were reported. The Singapore general population (approximately 4 million) served as the reference group for these estimations. Results A total of 9803 survivors of HNC (median [IQR] age at diagnosis, 58 [49-68] years; 7166 [73.1%] male) were identified. The most common HNC subsites were nasopharynx (4680 individuals [47.7%]), larynx (1228 individuals [12.5%]), and tongue (1059 individuals [10.8%]). A total of 337 individuals (3.4%) developed stroke over a median (IQR) follow-up of 42.5 (15.0-94.5) months. The overall SIRR was 2.46 (95% CI, 2.21-2.74), and the overall SIRD was 4.11 (95% CI, 3.37-4.85) strokes per 1000 person-years (PY). The cumulative incidence of stroke was 3% at 5 years and 7% at 10 years after HNC diagnosis. The SIRR was highest among individuals diagnosed at younger than 40 years (SIRR, 30.55 [95% CI, 16.24-52.35]). All population subsets defined by age, sex, race and ethnicity, HNC subsites (except tongue), stage, histology, and treatment modalities had increased risk of stroke compared with the general population. The SIRR and SIRD were significantly higher among individuals who had a primary radiation treatment approach (SIRR, 3.01 [95% CI, 2.64-3.43]; SIRD, 5.12 [95% CI, 4.18-6.29] strokes per 1000 PY) compared with a primary surgery approach (SIRR, 1.64 [95% CI, 1.31-2.05]; SIRD, 1.84 [95% CI, 0.923.67] strokes per 1000 PY). Conclusions and Relevance In this cross-sectional study of survivors of HNC, elevated stroke risks were observed across different age, subsites, and treatment modalities, underscoring the importance of early screening and intervention.
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Affiliation(s)
- Pui Lam Yip
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Huili Zheng
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Timothy Cheo
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Teng Hwee Tan
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Yiat Horng Leong
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Lea Choung Wong
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Jeremy Tey
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
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