Cardiovascular risk management in cancer survivors: Are we doing it right?

Temporal trends and risk factors associated with stroke mortality among cancer patients

BACKGROUND

This study aimed to explore the risk of stroke death (SD) in cancer patients, estimate rates, and identify risk factors associated with SD.

METHODS

In this retrospective study, we used the 17 National Cancer Institute Surveillance, Epidemiology, and End Results registries (2000-2020). A total of 5,922,533 patients diagnosed with their first primary cancer were included. The primary outcome was the standardized mortality ratio (SMR) of SD in cancer patients. Secondary outcomes included SD incidence rates and risk factors. Rates were calculated per 100,000 persons with the annual percentage change (APC).

RESULTS

Among included patients, 56,686 (2.0 %) died due to stroke. Compared to the general population, younger patients (≤39 years) (SMR: 2.31) and patients receiving no treatment (SMR: 1.36) had the highest risk. Cancer types with the fastest-declining SD rates were in the male genital (APC: -13.9 %) and breast (APC: -11.8 %). Older age (hazard ratio [HR]: 1.11, p < 0.001), male sex (HR: 1.06, p < 0.001), and non-white race (HR: 1.13, p < 0.001) were associated with increased risk of SD. Cancers of the nervous system (HR: 3.42, p < 0.001), respiratory (HR: 1.38, p < 0.001), and head and neck (HR: 1.37, p < 0.001) had higher risk of SD vs. breast cancer. Patients with primary chemotherapy (HR: 0.69, p < 0.001) and radiotherapy (HR: 0.69, p < 0.001) demonstrated less risk vs. those without treatment.

CONCLUSION

SD has declined over the years for both sexes and all cancer types. Older age, non-white race, and certain cancers (nervous system, respiratory system, and head and neck) pose significant risks for SD.

Anticancer Chemotherapy-Induced Atherosclerotic Cardiovascular Disease: A Comprehensive Review

The introduction of anticancer agents has transformed oncology, significantly improving survival rates. However, these therapies have introduced unintended cardiovascular risks, with atherosclerovascular disease (ASCVD) emerging as a leading cause of morbidity and mortality among cancer survivors. The development of ASCVD in this population involves multifactorial mechanisms, including endothelial dysfunction, oxidative stress, systemic inflammation, and disrupted lipid metabolism. This review examines the various mechanisms through which anticancer chemotherapy contributes to ASCVD and highlights strategies for risk assessment and management. Each class of anticancer agents presents distinct cardiovascular challenges: anthracyclines induce oxidative stress and endothelial damage, promoting foam cell formation and plaque progression; taxanes and vascular endothelial growth factor (VEGF) inhibitors impair lipid metabolism and vascular stability; anti-metabolites exacerbate endothelial injury through reactive oxygen species; and mTOR inhibitors, hormonal therapies, tyrosine kinase inhibitors, and immune checkpoint inhibitors disrupt lipid profiles and inflammatory pathways, increasing the risk of plaque rupture and thrombosis. Mitigating chemotherapy-induced ASCVD necessitates a comprehensive, multidisciplinary approach. Detailed pre-treatment cardiovascular risk assessments must address traditional and cancer-specific risk factors, including demographics, pre-existing conditions, and modifiable behaviors such as smoking and inactivity. Pharmacological interventions like statins and angiotensin-converting enzyme (ACE) inhibitors, paired with lifestyle modifications, are essential to reducing ASCVD risk. In resource-limited settings, cost-effective strategies should be prioritized to enhance accessibility. Establishing cardio-oncology units facilitates care coordination, while long-term surveillance enables timely detection and intervention. These strategies collectively improve cardiovascular outcomes and survivorship in diverse patient populations.

Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review

Cardiovascular and cancer outcomes intersect within the realm of cardio-oncology survivorship care, marked by disparities across ethnic, racial, social, and geographical landscapes. Although the clinical community is increasingly aware of this complex issue, effective solutions are trailing. To attain substantial public health impact, examinations of cancer types and cardiovascular risk mitigation require complementary approaches that elicit the patient's perspective, scale it to a population level, and focus on actionable population health interventions. Adopting such a multidisciplinary approach will deepen our understanding of patient awareness, motivation, health literacy, and community resources for addressing the unique challenges of cardio-oncology. Geospatial analysis aids in identifying key communities in need within both granular and broader contexts. In this review, we delineate a pathway that navigates barriers from individual to community levels. Data gleaned from these perspectives are critical in informing interventions that empower individuals within diverse communities and improve cardio-oncology survivorship.

A review regarding the article 'Dose-response association between cardiovascular health and mortality in cancer survivors'

Cardiovascular disease (CVD) and cancer are the two leading causes of morbidity and mortality in the world. The emerging field of cardio-oncology has revealed that these seemingly disparate disease processes are intertwined, owing to the cardiovascular sequelae of anticancer therapies, shared risk factors that predispose individuals to both cardiovascular disease and cancer, as well the possible potentiation of cancer growth by cardiac dysfunction. As a result, interest has increased in understanding the fundamental biological mechanisms that are central to the relationship between CVD and cancer. CVD and cancer frequently coincide in the same patient and often complicate each other. To date, much of the focus in cardio-oncology has been on the cardiovascular complications developed during cancer progression and as a result of cancer treatment. However, the reverse can also be true, and patients with CVD have been shown to be at increased risk of developing cancer (reverse cardio-oncology), as reviewed previously. Recently, the American Heart Association (AHA) updated the Life's Essential 8 (LE8) score, which captures modifiable risk factors, including smoking, body mass index, physical activity, sleep, dietary habits, blood pressure, fasting glucose, and total cholesterol levels, to assess CVH. Many studies have demonstrated a robust association between LE8 and CVD and all-cause mortality in the general population. Beyond assessment and monitoring, using metrics such as LE8 has the unique advantage to identify modifiable risk factors and refers cancer survivors for targeted interventions to manage their CVD risk. Future research in larger study samples is needed to investigate whether the optimal CVD defined by LE8 may differ in population subgroups and implement and evaluate CVD promotion interventions in the high-risk cancer survivor population.

Web-based nutrition: a useful resource for cancer patients?

Introduction

An accessible and affordable way to deliver behavior change programs to a large proportion of the growing community of cancer patients and survivors is through web-based methods of nutritional counselling.

Objective

The aim of this systematic review was to evaluate the effectiveness of web-based nutritional therapies targeting physical activity, diet, and/or weight control for cancer patients or survivors, primarily disseminated via modern technologies (mobile phone applications) or online.

Materials and methods

The authors conducted a structured search of the PubMed database. Studies that have focused on physical activity (PA) and dietary change and/or weight control in adolescent and adult cancer patients and survivors have reported outcomes conducted via a broad modality.

Results

Nine articles focused on web-based nutrition for patients with cancer and cancer survivors. They were conducted in the United States, Australia, Korea, China, and in the United Kingdom, and were published between 2018 and 2022 in a variety of scientific journals. The number of participants ranged from 20 to 159.

Conclusion

Web-based nutrition counselling helps cancer patients and survivors improve their dietary intake, impacts their weight and quality of life, and promotes a healthy lifestyle. Future research should evaluate (1) the differences in cost and coverage between face-to-face and web-based nutrition, (2) long-term outcomes, (3) cost-effectiveness, and last but not least, (4) the effectiveness of web-based nutrition in adolescents and children who suffer from cancer or who survived cancer, as nutritional status and body composition have a marked impact on clinical outcomes during and after treatment. The strength of this review lies in the large number of randomized controlled trials, which offer a guarantee of effectiveness and objectivity compared to cross-sectional studies.

Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review

Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.

Clinical response to lifestyle counseling for dyslipidemia and elevated blood pressure in childhood cancer survivors

BACKGROUND

Childhood cancer survivors (CCS) have increased risk of premature cardiovascular disease. Whether they respond similarly to lifestyle changes for elevated blood pressure (BP), body mass index (BMI), and dyslipidemia to those without history of childhood cancer is unknown.

PROCEDURE

This retrospective cohort study included CCS and 3:1 age- and sex-matched controls treated at Boston Children's Hospital Preventive Cardiology (2010-2019) using lifestyle management based on National Heart, Lung, and Blood Institute (NHLBI) guidelines. Change in BMI, BP, and lipids were analyzed.

RESULTS

We included 52 CCS and 162 controls with a median age of approximately 16 years. More CCS (84.3%) had elevated baseline fasting triglycerides (TG) than controls (49.4%) (p < .001). More CCS (62.5%) also had abnormal baseline high-density lipoprotein cholesterol (HDL-C) compared to controls (35.2%) (p = .001). Baseline BMI, BP, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) were similar between groups. Over 15 weeks [IQR: 10.5-26], CCS had greater decrease in TG than controls (72.5 vs. 17 mg/dl decrease, p = .095). BP improved in 5% of CCS versus 38% of controls (p = .008). For both, BMI, TC, LDL-C, and HDL-C remained stable. CCS with stem cell transplantation (SCT) had a TC increase of 5% (6 mg/dl) compared to a decrease of 9% (19 mg/dl) among CCS without SCT (p = .02).

CONCLUSIONS

CCS demonstrated similar improvement in lipids, but impaired BP lowering in response to lifestyle management compared to controls. Further prospective studies are needed to determine if earlier pharmaceutical treatment is warranted in this higher risk population and for the long-term risk reductions of these approaches.

Ruiz J, Nestares T, Carneiro-Barrera A. Multidisciplinary Prehabilitation and Postoperative Rehabilitation for Avoiding Complications in Patients Undergoing Resection of Colon Cancer: Rationale, Design, and Methodology of the ONCOFIT Study

ONCOFIT is a randomized clinical trial with a two-arm parallel design aimed at determining the influence of a multidisciplinary Prehabilitation and Postoperative Program (PPP) on post-surgery complications in patients undergoing resection of colon cancer. This intervention will include supervised physical exercise, dietary behavior change, and psychological support comparing its influence to the standard care. Primary and secondary endpoints will be assessed at baseline, at preoperative conditions, at the end of the PPP intervention (after 12 weeks) and 1-year post-surgery, and will include: post-surgery complications (primary endpoint); prolonged hospital length of stay; readmissions and emergency department call within 1-year after surgery; functional capacity; patient reported outcome measures targeted; anthropometry and body composition; clinical/tumor parameters; physical activity levels and sedentariness; dietary habits; other unhealthy habits; sleep quality; and fecal microbiota diversity and composition. Considering the feasibility of the present intervention in a real-life scenario, ONCOFIT will contribute to the standardization of a cost-effective strategy for preventing and improving health-related consequences in patients undergoing resection of colon cancer with an important clinical and economic impact, not only in the scientific community, but also in clinical practice.

Cardiovascular Disease in Adult Cancer Survivors: a Review of Current Evidence, Strategies for Prevention and Management, and Future Directions for Cardio-oncology

PURPOSE OF REVIEW

Cardiovascular disease is long-term complication of both cancer and anti-cancer treatment and can have significant ramifications for health-related quality of life and mortality. This narrative review explores the current evidence linking cardiovascular disease and cancer, as well as exploring strategies for the prevention and management of cardiovascular disease, and outlines future opportunities in the field of cardio-oncology.

RECENT FINDINGS

Cancer confers risk for various cardiovascular diseases including heart failure, cardiomyopathy, arrhythmia, coronary heart disease, stroke, venous thromboembolism, and valvular heart disease. Cancer treatment, in particular agents such as platinum-based chemotherapy, anthracyclines, hormonal treatments, and thoracic radiotherapy, further increases risk. While cardiovascular disease can be identified early and effectively managed in cancer survivors, cardiovascular screening and management does not typically feature in routine long-term cancer care of adult cancer survivors. Cancer and cancer treatment can accelerate the development of cardiovascular disease. Further research into screening and management strategies for cardiovascular disease, along with evidence-based guidelines, is required to ensure adult cancer survivors receive appropriate long-term care.