Cardiometabolic Comorbidities in Cancer Survivors

Weight change and cardiovascular disease incidence in breast cancer survivors: a nationwide cohort study

BACKGROUND

Breast cancer survivors (BCS) face a higher risk of cardiovascular disease (CVD) due to treatment-related cardiotoxicity and pre-existing conditions. We investigated how post-diagnosis weight changes and obesity impact CVD risk in this population.

METHOD

Using the Korean National Health Insurance Service database (2010-2019), BCS without previous history of CVD were enrolled. Weight change was determined using standardized anthropometric protocols during biennial health examinations pre- and post-diagnosis. The primary outcome was incident CVD, a composite of myocardial infarction (MI) and ischemic stroke. Adjusted hazard ratios (aHRs) and confidence intervals (CIs) were estimated, accounting for cardiovascular risk factors, cancer treatments, and sociodemographic variables.

RESULTS

During a mean follow-up of 3.70 years among the 42,547 BCS (mean [SD] age 53.4 [9.4] years), substantial weight gain (> 10%) was associated with increased CVD risk (aHR 1.66, 95% CI 1.05-2.62) and MI risk (aHR 1.83, 95% CI 1.01-3.33) compared to those who maintained their weight. The association between change in obesity status and CVD risk was not significant. Among BCS with sustained obesity, CVD risk was more pronounced in younger survivors (< 50 years) (aHR 3.58, 95% CI 1.94-6.61), and in those using tamoxifen (aHR 1.74, 95% CI 1.11-2.75) (P-interactions < 0.05).

CONCLUSIONS

Our findings suggest that BCS who experience substantial weight gain post-diagnosis have an increased risk of CVD. Further intervention studies (e.g., GLP-1 agonist) are needed to ascertain the effects of weight changes on CVD risks in BCS.

Addressing cardiovascular risks with a goal to prevent cardiovascular complications in patients undergoing antihormonal therapy for prostate cancer

Over 1 million cases of prostate cancer are reported every year, and it is the second most common cancer in men. Androgen deprivation therapy (ADT) is a hallmark treatment for prostate cancer but is associated with the development or exacerbation of cardiovascular disease. The most common cause of non-cancer death in patients with prostate cancer is cardiovascular disease. Thus, a better understanding of the prevalence of cardiovascular toxicity across all therapies, management of potential cardiovascular complications, and prevention of cardiovascular events is essential as treatments continue to evolve. In this article, the first in a 2-part series, we provide a review of the current landscape of ADT therapy and its association with cardiovascular disease, summarize recent clinical trial data evaluating cardiovascular outcomes, and provide insights on the management of cardiovascular risk factors and adverse events for clinicians managing this high-risk population of men undergoing potentially cardiotoxic treatment for prostate cancer.

Principles of optimal multidisciplinary management of prostate cancer in clinical practice

Advances in the diagnosis and management of prostate cancer have significantly changed the disease landscape. While benefiting from better oncological outcomes, patients are now experiencing higher rates of non-cancer comorbidities, including cardiovascular disease. The increasing impact of cardiovascular disease in those with prostate cancer led to the expanding role of cardio-oncology professionals in enhancing the multidisciplinary care of these patients. As a result, the International Cardio-Oncology Society (IC-OS) launched a 4-webinar series in collaboration with the European Association of Urology and the Canadian Urology Association to inform best practices in the multidisciplinary care of patients with prostate cancer. This program highlighted currently recommended diagnostic and treatment strategies from urology, oncology, and cardiology and emphasized knowledge gaps and future directions. In this article, which is the second in a 2-part series, we review challenging cases that were presented and discussed among a multidisciplinary international panel and highlight ongoing research and future directions from both urology/oncology and cardio-oncology.

Role of Cardiovascular Health in the Bidirectional Progression Trajectories Between Cardiovascular Disease, Type 2 Diabetes, and Cancer

BACKGROUND

There existed bidirectional associations of cardiovascular disease (CVD) and type 2 diabetes (T2D) with cancer, partly attributed to their shared risk factors. We aimed to explore the role of cardiovascular health (CVH) in bidirectional transitions between CVD, T2D, and cancer.

METHODS

Based on the UK Biobank, we used 2 subcohorts: a disease-free cohort of 277 997 individuals without cancer, CVD, and T2D; and a disease survivor cohort consisting of 61 971 cases with cancer, CVD, and T2D at baseline. The CVH was assessed on the basis of Life's Essential 8 score. We conducted the multistate model and Cox proportional hazards model to explore the role of CVH in bidirectional transitions between CVD, T2D, and cancer in disease-free and disease survivor cohorts, respectively.

RESULTS

High CVH was significantly associated with a lower transition risk from CVD to cancer (hazard ratio, 0.822 [95% CI, 0.693-0.975]). On the other hand, increased CVH was related to reduced risks of progression from cancer to CVD and T2D (both P for trend<0.001), particularly in the high CVH group. For disease survivor cohorts, per 10-point increase in CVH was associated with >10% lower cancer risk in CVD and T2D cases, and a 16% and 42% reduction in the risk of incident CVD and T2D among cancer survivors, respectively.

CONCLUSIONS

High CVH was related to a decreased risk of bidirectional transitions between CVD, T2D, and cancer. This highlighted the significance of maintaining high CVH throughout the life span for the primary prevention of CVD, T2D, and cancer.

Pulmonary Embolism-Related Mortality in Patients With Cancer

Importance

Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in patients with cancer in the US and worldwide.

Objectives

To assess the trends in PE-related mortality from 2011 to 2020 among US patients with cancer across age, sex, ethnic and racial groups, urbanicity, and regionality.

Design, Setting, and Participants

This cohort study used the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research data system to determine national trends in age-adjusted mortality rates (AAMRs) due to acute PE among US patients with cancer aged 15 years or older from January 2011 to December 2020. Concomitant trends in cancer mortality and incidence that may have contributed to PE-related mortality were obtained from US Cancer Statistics. Data were analyzed from September to November 2024.

Exposure

PE-related mortality.

Main Outcomes and Measures

The primary outcome was PE-related deaths among individuals with cancer. AAMRs and cancer incidence were assessed using joinpoint regression modeling, expressed as an average annual percentage change (AAPC) with relative 95% CIs.

Results

From 2011 to 2020, a total of 27 280 194 individuals aged 15 years or older (13 897 519 male [50.9%]; 13 382 675 female [49.1%]) died in the US. The AAMR for PE-related mortality in patients with cancer increased during this time period (AAPC, 2.5%; 95% CI, 1.4% to 3.6%; P = .001), without differences between sexes (P for parallelism = .38). The AAMR increased among those aged 15 to 64 years (AAPC, 3.2%; 95% CI, 1.9% to 4.6%; P = .001), non-Hispanic and non-Latinx White individuals (AAPC, 2.7%; 95% CI, 1.52% to 3.94%; P = .001), non-Hispanic and non-Latinx Black or African American individuals (AAPC, 2.2%; 95% CI, 0.7% to 3.7%; P = .001), Hispanic and Latinx individuals (AAPC, 2.6%; 95% CI, 0.7% to 4.5%; P = .006), and among individuals residing in the Southern US (AAPC, 3.7%; 95% CI, 1.3% to 6.2%; P = .003). During the same period, age-adjusted cancer incidence and cancer-related mortality decreased while the absolute number of new cancer diagnoses and cancer-related deaths increased.

Conclusions and Relevance

This cohort study found that despite decreases in cancer-related mortality rates, age-adjusted PE-related mortality in US patients with cancer increased over the last decade; concerning trends included rising PE-related mortality in younger individuals aged 15 to 64 years, particular ethnic and racial groups, and the Southern region of the US. Recognition of such patterns may inform further research into thromboprophylaxis and treatment of PE as a complication of cancer and cancer-directed therapy.

Sodium-glucose cotransporter 2 inhibitors and the cancer patient: from diabetes to cardioprotection and beyond

Sodium-glucose cotransporter 2 inhibitors (SGLT2i), a new drug class initially designed and approved for treatment of diabetes mellitus, have been shown to exert pleiotropic metabolic and direct cardioprotective and nephroprotective effects that extend beyond their glucose-lowering action. These properties prompted their use in two frequently intertwined conditions, heart failure and chronic kidney disease. Their unique mechanism of action makes SGLT2i an attractive option also to lower the rate of cardiac events and improve overall survival of oncological patients with preexisting cardiovascular risk and/or candidate to receive cardiotoxic therapies. This review will cover biological foundations and clinical evidence for SGLT2i modulating myocardial function and metabolism, with a focus on their possible use as cardioprotective agents in the cardio-oncology settings. Furthermore, we will explore recently emerged SGLT2i effects on hematopoiesis and immune system, carrying the potential of attenuating tumor growth and chemotherapy-induced cytopenias.

Cardiovascular diseases in patients with cancer: A comprehensive review of epidemiological trends, cardiac complications, and prognostic implications

ABSTRACT

This article provides an overview of the current evidence on the epidemiology, overlapping risk factors, and pathophysiology of cardiovascular disease (CVD) in patients with cancer. It explores the cardiotoxic effects of anticancer therapy and their impact on prognosis. Although cancer survival rates have improved over the last two decades, the risk of CVD has risen over time in patients with cancer. CVD and cancer share similar risk factors and a common pathophysiology involving inflammation. Many chemotherapeutic agents used to treat cancer are associated with cardiovascular complications (such as heart failure, myocardial infarction, and thrombosis). Current evidence indicates a significant burden of CVD in patients with cancer, particularly in the first year following cancer diagnosis, with elevated risk persisting beyond this period. This short- and long-term risk of CVD may vary depending on the cancer type and treatment regimen. Early identification of potential cardiovascular risk in patients with cancer, can lead to more favorable clinical and survival outcomes. Given the acute and long-term consequences, patients with cancer require increased cardiovascular care and lifestyle optimization. This article offers valuable insights into the cardiovascular burden and needs of patients with cancer. It is intended for a general medical research readership interested in the intersection of cardiology and oncology.

A novel machine learning-based cancer-specific cardiovascular disease risk score among patients with breast, colorectal, or lung cancer

BACKGROUND

Cancer patients have up to a 3-fold higher risk for cardiovascular disease (CVD) than the general population. Traditional CVD risk scores may be less accurate for them. We aimed to develop cancer-specific CVD risk scores and compare them with conventional scores in predicting 10-year CVD risk for patients with breast cancer (BC), colorectal cancer (CRC), or lung cancer (LC).

METHODS

We analyzed adults diagnosed with BC, CRC, or LC between 2005 and 2012. An machine learning (ML) Extreme Gradient Boosting algorithm ranked 40-50 covariates for predicting CVD for each cancer type using SHapley Additive exPlanations values. The top 10 ML-predictors were used to create predictive equations using logistic regression and compared with American College of Cardiology (ACC)/American Heart Association (AHA) Pooled Cohort Equations (PCE), Predicting Risk of cardiovascular disease EVENTs (PREVENT), and Systematic COronary Risk Evaluation-2 (SCORE2) using the area under the curve (AUC).

RESULTS

We included 10 339 patients: 55.5% had BC, 15.6% had CRC, and 29.7% had LC. The actual 10-year CVD rates were: BC 21%, CRC 10%, and LC 28%. The predictors derived from the ML algorithm included cancer-specific and socioeconomic factors. The cancer-specific predictive scores achieved AUCs of 0.84, 0.76, and 0.83 for BC, CRC, and LC, respectively, and outperformed PCE, PREVENT, and SCORE2, increasing the absolute AUC values by up to 0.31 points (with AUC ranging from 0 to 1). Similar results were found when excluding patients with cardiac history or advanced cancer from the analysis.

CONCLUSIONS

Cancer-specific CVD predictive scores outperform conventional scores and emphasize the importance of integrating cancer-related covariates for precise prediction.

Effects of smoking behavior change on diabetes incidence after cancer development: A nationwide cohort study

AIM

Cigarette smoking and diabetes mellitus (DM) increase risks of cardiovascular diseases and all-cause mortality in cancer survivors. An increased risk of DM incidence in cancer survivors has been observed and smoking is an important modifiable risk factor for DM development in the general population. Thus, we investigated the association between smoking behavior change after cancer diagnosis and DM incidence in cancer survivors.

METHODS

This retrospective cohort study using the Korean National Health Insurance System database included patients with newly diagnosed cancers between 2010 and 2016. Smoking behavior changes after cancer diagnosis were categorized as never smoker, ex-smoker, quitter, smoking starter, and persistent smoker. The associations between smoking behavior changes and DM incidence in overall and specific cancers were investigated using Cox regression analyses.

RESULTS

Of the 263,940 cancer survivors, 67.6 % were never smokers, 16.0 % were ex-smokers, 9.3 % were quitters, 1.0 % were smoking starters, and 6.2 % were persistent smokers. During a mean follow-up of 4.0 years, 12,175 patients were diagnosed with DM after cancer development. Compared to the never smokers, the adjusted hazard ratios (95 % confidential interval) of DM incidence were 1.06 (1.00-1.13) for ex-smokers, 1.45 (1.35-1.54) for quitters, 1.46 (1.25-1.71) for starters, and 1.57 (1.45-1.69) for persistent smokers.

CONCLUSION

Compared with never smokers, cancer survivors who engaged smoking at any point before or after cancer diagnosis showed an increased risk of DM incidence after cancer diagnosis. Cancer survivors should be advised to quit smoking promptly and to maintain abstinence throughout cancer survivorship.

How We Monitor Cardiac Health in Breast Cancer Survivors

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Cardiovascular Considerations After Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations

Cancer survivors, particularly those treated with anthracyclines and chest radiation, face an elevated risk of cancer therapy-related cardiovascular toxicity. These complications affect not only physical health, but also life expectancy. Risk factors for cancer therapy-related cardiovascular toxicity include age at which cancer treatment was received, the use of (potentially) cardiotoxic cancer therapies, and the presence of concomitant cardiovascular risk factors. Current guidelines provide recommendations for cardiovascular surveillance after cancer therapy, including type and frequency. All cancer survivors are advised to undergo annual clinical screenings and optimization of cardiovascular risk factors. Those at higher risk should undergo additional cardiovascular testing. This document aims to summarize the available evidence, present practical recommendations, and outline existent gaps in the current literature regarding cardiovascular care after cancer therapies.

Changes in Physical Activity and Cardiovascular Disease Risk in Cancer Survivors: A Nationwide Cohort Study

Background

Cancer survivors face an elevated risk of cardiovascular disease, with physical inactivity after cancer treatment potentially worsening this risk.

Objectives

The aim of this study was to investigate the association between physical activity before and after a cancer diagnosis and the risk for heart disease.

Methods

A nationwide cohort of 269,943 cancer survivors (mean age 56.3, 45.7% men) was evaluated for physical activity adherence 2 years before and after diagnosis. The primary outcomes were the incidence of myocardial infarction (MI), heart failure (HF), and atrial fibrillation. Subdistribution HRs (sHRs) and 95% CIs were calculated using Gray's method, accounting for death as a competing risk.

Results

Over a follow-up period of 1,111,329.28 person-years, compared with those who remained inactive, persistent physical activity was associated with a 20% reduction in MI risk (sHR: 0.80; 95% CI: 0.70-0.91) and a 16% reduction risk in HF risk (sHR: 0.84; 95% CI: 0.78-0.90). Initiating physical activity after a cancer diagnosis was linked to an 11% lower risk for MI (sHR: 0.89; 95% CI: 0.79-0.99) and a 13% lower risk for HF (sHR: 0.87; 95% CI: 0.82-0.93). Being active only before diagnosis was associated with a 20% lower risk for MI (sHR: 0.80; 95% CI: 0.71-0.91) and a 6% lower risk for HF (sHR: 0.94; 95% CI: 0.88-1.00). No association was observed between physical activity and atrial fibrillation risk. Associations varied by primary cancer site.

Conclusions

These findings underscore the importance of maintaining physical activity for cardiovascular health in cancer survivors and suggest that physical activity before a diagnosis may offer enduring protection against ischemic heart disease and cardiac dysfunction.

Trends in cancer and heart failure related mortality in adult US population: A CDC WONDER database analysis from 1999 to 2020

BACKGROUND

With the advent of novel chemotherapy, survival of patients with cancer has improved. However, people with cancer have an increased risk of heart failure (HF). Conversely, HF-related mortality may undermine survival among people with cancer. We aim to analyze the trends of mortality in people with HF and cancer in the adult US population.

METHODS

We conducted an examination of death certificates sourced from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) database, from the years 1999 to 2020. Mortality in adults with HF and cancer was assessed. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent change were reported.

RESULTS

Between 1999 and 2020, 621,783 deaths occurred from HF in people with cancer. The AAMR declined from 16.4 in 1999 to 11.9 in 2017, after which an increase to 14.5 was observed in 2020. Men had consistently higher overall AAMR as compared to women (men = 18.1 vs women = 9.9). Similar AAMR was observed between non-Hispanic (NH) Blacks/African Americans (13.9) and NH Whites (13.3), with lower in American Indian/Alaska Native (9.6) and Hispanics (7.4). Asian/Pacific Islanders reported the lowest AAMR (5.7). The Midwestern region reported the highest AAMR (14.8). We observed the highest AAMR amongst the older population (61.4).

CONCLUSION

The mortality rates of people with HF and cancer are increasing in the adult U.S.

POPULATION

This underscores the need for increased screening, aggressive management, and subsequent surveillance of people at risk or with manifested HF in people with cancer.

European Association for the Study of Obesity (EASO) Position Statement on Medical Nutrition Therapy for the Management of Individuals with Overweight or Obesity and Cancer

Obesity, a prevalent and multifactorial disease, is linked to a range of metabolic abnormalities, including insulin resistance, dyslipidemia, and chronic inflammation. These imbalances not only contribute to cardiometabolic diseases but also play a significant role in cancer pathogenesis. The rising prevalence of obesity underscores the need to investigate dietary strategies for effective weight management for individuals with overweight or obesity and cancer. This European Society for the Study of Obesity (EASO) position statement aimed to summarize current evidence on the role of obesity in cancer and to provide insights on the major nutritional interventions, including the Mediterranean diet (MedDiet), the ketogenic diet (KD), and the intermittent fasting (IF), that should be adopted to manage individuals with overweight or obesity and cancer. The MedDiet, characterized by high consumption of plant-based foods and moderate intake of olive oil, fish, and nuts, has been associated with a reduced cancer risk. The KD and the IF are emerging dietary interventions with potential benefits for weight loss and metabolic health. KD, by inducing ketosis, and IF, through periodic fasting cycles, may offer anticancer effects by modifying tumor metabolism and improving insulin sensitivity. Despite the promising results, current evidence on these dietary approaches in cancer management in individuals with overweight or obesity is limited and inconsistent, with challenges including variability in adherence and the need for personalized dietary plans.

Anthracycline Cardiotoxicity in Adult Cancer Patients: JACC: CardioOncology State-of-the-Art Review

Since their introduction in the 1960s, anthracyclines have been a significant breakthrough in oncology, introducing dramatic changes in the treatment of solid and hematologic malignancies. Although new-generation targeted drugs and cellular therapies are revolutionizing contemporary oncology, anthracyclines remain the cornerstone of treatment for lymphomas, acute leukemias, and soft tissue sarcomas. However, their clinical application is limited by a dose-dependent cardiotoxicity that can reduce cardiac performance and eventually lead to overt heart failure. The field of cardio-oncology has emerged to safeguard the cardiovascular health of cancer patients receiving these therapies. It focuses on controlling risk factors, implementing preventive strategies, ensuring appropriate surveillance, and managing complications. This state-of-the-art review summarizes the current indications for anthracyclines in modern oncology, explores recent evidence on pathophysiology and epidemiology, and discusses advances in cardioprotection measures in the anthracycline-treated patient. Additionally, it highlights key clinical challenges and research gaps in this area.

The Role of Nursing in the Delivery of Cardio-Oncology

OPINION STATEMENT

Nurses are the "heart of patient care" and in the forefront of the health care delivery for cardio-oncology patients. Nurses play a critical central role in maximizing longitudinal health of cancer patients and survivors through the prevention of cardiovascular complications throughout the patient's cancer care journey. Nurses function in a variety of roles such as nurse clinicians, advanced practice nurses (APNs)or nurse practitioners (NPs), patient educators, managers, nurse navigators or nurse researchers. The role of nurses, particularly the advanced practice nurses as key members in delivering cardio-oncology care is evolving. However, despite the rapidly increasing growth of cardio oncology programs globally, a pivotal need remains to develop and provide formalized training programs for nurses, NPs and APNs. At present, no formal academic cardio-oncology nurse training program or certification exists. There is clearly more work to be done on the role of nurses in cardio-oncology care. As cardio-oncology evolves to become a key specialty with dedicated services being established across the globe, the role of the nurse in delivering this service is critical and a concerted collaborative approach between the two distinct specialties of cardiology and oncology needs to ensure the nursing workforce is educationally prepared and confident to treat and manage cardio-oncology patients.

Cardiovascular disease and cancer: shared risk factors and mechanisms

Cardiovascular disease (CVD) and cancer are among the leading causes of morbidity and mortality globally, and these conditions are increasingly recognized to be fundamentally interconnected. In this Review, we present the current epidemiological data for each of the modifiable risk factors shared by the two diseases, including hypertension, hyperlipidaemia, diabetes mellitus, obesity, smoking, diet, physical activity and the social determinants of health. We then review the epidemiological data demonstrating the increased risk of CVD in patients with cancer, as well as the increased risk of cancer in patients with CVD. We also discuss the shared mechanisms implicated in the development of these conditions, highlighting their inherent bidirectional relationship. We conclude with a perspective on future research directions for the field of cardio-oncology to advance the care of patients with CVD and cancer.

Association between physical activity changes and risk of incident ischemic stroke following cancer diagnosis: A nationwide retrospective cohort study

BACKGROUND

Physical inactivity is prevalent after cancer treatment, which could increase ischemic stroke risk in cancer survivors. This study investigated the association between physical activity change from pre- to post-diagnosis and ischemic stroke risk among cancer survivors.

METHODS

Using data from the Korean National Health Insurance Service database, 269,943 cancer survivors (mean [SD] age, 56.3 [12.1] years; 45.7% male) with no history of cardiovascular disease were evaluated based on changes in physical activity from pre- to post-diagnosis. Using the Fine-Gray model, subdistribution hazard ratios (sHRs) and 95% confidence intervals (CIs) for ischemic stroke risk were calculated, considering death as a competing risk.

RESULTS

After cancer diagnosis, 62.0% remained inactive, 10.1% remained active, 16.6% became active, and 11.4% became inactive. During a mean (SD) follow-up of 4.1 (2.0) years, being active both pre- and post-diagnosis was associated with a 15% decreased risk of ischemic stroke (sHR, 0.85; 95% CI, 0.75-0.96), compared with those who remained inactive. Cancer survivors who became active and inactive post-diagnosis showed a 16% and 11% lower ischemic stroke risk (sHR, 0.84; 95% CI, 0.75-0.93; sHR, 0.89; 95% CI, 0.79-0.99), respectively, than those who remained inactive. Analysis by the primary cancer site did not substantially differ from the main findings.

CONCLUSIONS

Physical activity is associated with reduced ischemic stroke risk among cancer survivors. The potential benefits of physical activity are not limited to individuals who were physically active before cancer diagnosis, thus preventive strategies against ischemic stroke should emphasize physical activity throughout the cancer journey.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being. Furthermore, we discuss the outcome implications of these cardiometabolic risk factors on cardiovascular disease development, future cardiovascular events, and overall survival, supported by studies showing improved outcomes through exercise and risk factor control.

Metformin use correlated with lower risk of cardiometabolic diseases and related mortality among US cancer survivors: evidence from a nationally representative cohort study

BACKGROUND

In the USA, the prolonged effective survival of cancer population has brought significant attention to the rising risk of cardiometabolic morbidity and mortality in this population. This heightened risk underscores the urgent need for research into effective pharmacological interventions for cancer survivors. Notably, metformin, a well-known metabolic regulator with pleiotropic effects, has shown protective effects against cardiometabolic disorders in diabetic individuals. Despite these promising indications, evidence supporting its efficacy in improving cardiometabolic outcomes in cancer survivors remains scarce.

METHODS

A prospective cohort was established using a nationally representative sample of cancer survivors enrolled in the US National Health and Nutrition Examination Survey (NHANES), spanning 2003 to 2018. Outcomes were derived from patient interviews, physical examinations, and public-access linked mortality archives up to 2019. The Oxidative Balance Score was utilized to assess participants' levels of oxidative stress. To evaluate the correlations between metformin use and the risk of cardiometabolic diseases and related mortality, survival analysis of cardiometabolic mortality was performed by Cox proportional hazards model, and cross-sectional analysis of cardiometabolic diseases outcomes was performed using logistic regression models. Interaction analyses were conducted to explore the specific pharmacological mechanism of metformin.

RESULTS

Among 3995 cancer survivors (weighted population, 21,671,061, weighted mean [SE] age, 62.62 [0.33] years; 2119 [53.04%] females; 2727 [68.26%] Non-Hispanic White individuals), 448 reported metformin usage. During the follow-up period of up to 17 years (median, 6.42 years), there were 1233 recorded deaths, including 481 deaths from cardiometabolic causes. Multivariable models indicated that metformin use was associated with a lower risk of all-cause (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.47-0.81) and cardiometabolic (HR, 0.65; 95% CI, 0.44-0.97) mortality compared with metformin nonusers. Metformin use was also correlated with a lower risk of total cardiovascular disease (odds ratio [OR], 0.41; 95% CI, 0.28-0.59), stroke (OR, 0.44; 95% CI, 0.26-0.74), hypertension (OR, 0.27; 95% CI, 0.14-0.52), and coronary heart disease (OR, 0.41; 95% CI, 0.21-0.78). The observed inverse associations were consistent across subgroup analyses in four specific cancer populations identified as cardiometabolic high-risk groups. Interaction analyses suggested that metformin use as compared to non-use may counter-balance oxidative stress.

CONCLUSIONS

In this cohort study involving a nationally representative population of US cancer survivors, metformin use was significantly correlated with a lower risk of cardiometabolic diseases, all-cause mortality, and cardiometabolic mortality.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being.

Atherosclerotic Cardiovascular Events in Cancer Patients Treated With Immune Checkpoint Inhibitors: A Retrospective Cohort Study

BACKGROUND

Immune checkpoint inhibitors (ICIs) are effective therapies for numerous cancers, but have been associated with atherosclerotic cardiovascular disease (ASCVD). This study aimed to identify predictors for ASCVD events among cancer patients treated with ICIs and the cardiovascular risk factor (CVRF) control of those who developed ASCVD.

METHOD

A single-centre retrospective study of 366 cancer patients who received ICIs from 2018 to 2020 was performed. Demographic, baseline CVRF, cancer history, and ICI regimen data were obtained from medical records. The primary end point of ASCVD events was defined as myocardial infarction, coronary revascularisation, ischaemic stroke, or acute limb ischaemia. Cox proportional multivariable modelling and competing risks analysis were performed to assess ASCVD predictors. Descriptive analysis was performed to describe CVRF management among those who developed ASCVD events.

RESULTS

Over a median follow-up of 3.4 years (2.8-4.3), 26 patients (7.1%) experienced 27 ASCVD events (seven myocardial infarction, one coronary revascularisation, 13 ischaemic stroke, and six acute limb ischaemia events). There were 226 (61.8%) cancer-related deaths and no cardiac deaths. History of ASCVD before ICI initiation was independently associated with ASCVD events on traditional Cox modelling (hazard ratio [HR] 4.00; 95% confidence interval [CI] 1.79-8.91; p<0.01) and competing risks analysis (HR 4.23; 95% CI 1.87-9.60; p<0.01). A total of 17 patients developed ASCVD events after ICI cessation (median 1.4 years). Among those with ASCVD events, 12 had prior ASCVD, 16 had hypertension, nine had hypercholesterolaemia, and four had diabetes, and nine were actively smoking. Variable prescription of cardiovascular preventative therapies was noted.

CONCLUSIONS

History of ASCVD was associated with subsequent ASCVD events among patients treated with ICIs, which could occur even after active treatment was stopped. Identification and aggressive management of modifiable CVRFs should be considered throughout cancer survivorship in patients who received ICI treatment.

Changes in physical activity and diabetes risk after cancer diagnosis: a nationwide cohort study

PURPOSE

Physical activity has the potential to reduce the risk of diabetes after cancer diagnosis. However, current evidence supporting its effects is limited. This study aims to examine the associations between changes in physical activity and subsequent risk of diabetes among cancer survivors.

METHODS

A total of 264,250 cancer survivors (mean age 56.7 (12.5) years, 44.2% males) without a prior history of diabetes were assessed for adherence to physical activity both before and after their diagnosis. The primary outcome was incident diabetes. The Fine-Gray proportional sub-distribution hazards model was used to calculate sub-distribution hazard ratios (sHRs) and 95% confidence intervals (CIs) for diabetes risk, considering death as a competing risk.

RESULTS

Over a follow-up of 1,065,802 person-years, maintaining regular physical activity from pre-diagnosis was associated with a 10% reduced risk of diabetes after cancer diagnosis (sHR 0.90, 95% CI 0.85-0.96), considering traditional diabetes risk factors, sociodemographics, and primary cancer sites. Cancer survivors who became active and inactive after their cancer diagnosis exhibited a marginally decreased risk of diabetes (sHR 0.98, 95% CI 0.93-1.03; sHR 0.97, 95% CI 0.92-1.03). The strength and direction of the association varied depending on the primary site of cancer.

CONCLUSIONS

Regular physical activity starting before a cancer diagnosis is associated with a lower risk of diabetes following the diagnosis, independent of established diabetes risk factors.

IMPLICATIONS FOR CANCER SURVIVORS

The study underscores the importance of engaging in sufficient physical activity to mitigate the risk of diabetes in cancer survivors.

Cardio-oncology rehabilitation: are we ready?

Cardio-oncology rehabilitation (CORE) is not only an essential component of cancer rehabilitation but also a pillar of preventive cardio-oncology. Cardio-oncology rehabilitation is a comprehensive model based on a multitargeted approach and its efficacy has been widely documented; when compared with an 'exercise only' programme, comprehensive CORE demonstrates a better outcome. It involves nutritional counselling, psychological support, and cardiovascular (CV) risk assessment, and it is directed to a very demanding population with a heavy burden of CV diseases driven by physical inactivity, cancer therapy-induced metabolic derangements, and cancer therapy-related CV toxicities. Despite its usefulness, CORE is still underused in cancer patients and we are still at the dawning of remote models of rehabilitation (tele-rehabilitation). Not all CORE is created equally: a careful screening procedure to identify patients who will benefit the most from CORE and a multidisciplinary customized approach are mandatory to achieve a better outcome for cancer survivors throughout their cancer journey. The aim of this paper is to provide an updated review of CORE not only for cardiologists dealing with this peculiar population of patients but also for oncologists, primary care providers, patients, and caregivers. This multidisciplinary team should help cancer patients to maintain a healthy and active life before, during, and after cancer treatment, in order to improve quality of life and to fight health inequities.

Ceramides: a potential cardiovascular biomarker in young adult childhood cancer survivors?

Aims

The aim of this study was to investigate circulating ceramides involved in cardiovascular disease (CVD) in young adult childhood cancer survivors (CCS) and their correlations to previously reported adverse cardiovascular changes in this cohort.

Methods and results

Fifty-seven CCS and 53 healthy controls (age 20-30 years) were studied. Plasma long-chain ceramides, known to be cardiotoxic (C16:0, C18:0, C24:0, and C24:1), were analysed by mass spectrometry. The coronary event risk test 2 (CERT2) score was calculated from the ceramide data. Cardiac and carotid artery ultrasound data and lipid data available from previous studies of this cohort were used to study partial correlations with ceramide and CERT2 score data. All four analysed ceramides were elevated in CCS compared with controls (P ≤ 0.012). The greatest difference was noted for C18:0, which was 33% higher in CCS compared with controls adjusted for sex, age, and body mass index (BMI) (P < 0.001). The CERT2 score was higher in CCS compared with controls (P < 0.001). In the CCS group, 35% had a high to very high CERT2 score (7-12) when compared with 9% in the control group (P < 0.001). The CCS subgroup with a CERT2 score ≥ 7 had higher heart rate, systolic blood pressure, and higher levels of apolipoprotein B compared with CCS with a CERT2 score < 6 (P ≤ 0.011). When adjusted for age, sex, and BMI, CERT2 score was significantly correlated with arterial stiffness, growth hormone, and cranial radiotherapy (P < 0.044).

Conclusion

Ceramides could be important biomarkers in understanding the pathophysiology of CVD and in predicting CVD disease risk in young adult CCS.

Blood pressure surveillance in cancer patients treated with immune checkpoint inhibitors

Immune checkpoint inhibitors (ICI) are cancer therapies that have been associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). Blood pressure (BP) measurements are routinely performed during day oncology center visits for administration of ICI therapy but are often not assessed temporally to screen and monitor hypertension, which could independently increase the risk of ASCVD in cancer survivorship. This study reports the feasibility of using serial BP measurements from routine visits to day oncology center to diagnose and monitor hypertension control in cancer patients receiving ICIs.

The underutilization of preventive cardiovascular measures in patients with cancer: an analysis of the Behavioural Risk Factor Surveillance System, 2011-22

AIMS

This study aimed to characterize the influence of a cancer diagnosis on the use of preventive cardiovascular measures in patients with and without cardiovascular disease (CVD).

METHODS AND RESULTS

Data from the Behavioural Risk Factor Surveillance System Survey (spanning 2011-22) were used. Multivariable logistic regression models adjusted for potential confounders were applied to calculate average marginal effects (AME), the average difference in the probability of using a given therapy between patients with and without cancer. Outcomes of interest included the use of pharmacological therapies, physical activity, smoking cessation, and post-CVD rehabilitation. Among 5 012 721 respondents, 579 114 reported a history of CVD (coronary disease or stroke), and 842 221 reported a diagnosis of cancer. The association between cancer and the use of pharmacological therapies varied between those with vs. without CVD (P-value for interaction: <0.001). Among patients with CVD, a cancer diagnosis was associated with a lower use of blood pressure-lowering medications {AME: -1.46% [95% confidence interval (CI): -2.19% to -0.73%]}, lipid-lowering medications [AME: -2.34% (95% CI: -4.03% to -0.66%)], and aspirin [AME: -6.05% (95% CI: -8.88% to -3.23%)]. Among patients without CVD, there were no statistically significant differences between patients with and without cancer regarding pharmacological therapies. Additionally, cancer was associated with a significantly lower likelihood of engaging in physical activity in the overall cohort and in using post-CVD rehabilitation regimens, particularly post-stroke rehabilitation.

CONCLUSION

Preventive pharmacological agents are underutilized in those with cancer and concomitant CVD, and physical activity is underutilized in patients with cancer in those with or without CVD.

LAY SUMMARY

•This paper compared the use of preventive cardiovascular measures, both pharmaceutical and non-pharmaceutical, in patients with and without cancer.•In patients with cardiovascular disease and cancer, there is a lower use of preventive cardiovascular medications compared with those with cardiovascular disease but without cancer. This includes a lower utilization of blood pressure-lowering medications, cholesterol-lowering medications, and aspirin.•Patients with cancer reported lower levels of exercise but higher levels of smoking cessation compared with those without cancer.

Cancer survivorship at heart: a multidisciplinary cardio-oncology roadmap for healthcare professionals

In cancer, a patient is considered a survivor from the time of initial diagnosis until the end of life. With improvements in early diagnosis and treatment, the number of cancer survivors (CS) has grown considerably and includes: (1) Patients cured and free from cancer who may be at risk of late-onset cancer therapy-related cardiovascular toxicity (CTR-CVT); (2) Patients with long-term control of not-curable cancers in whom CTR-CVT may need to be addressed. This paper highlights the importance of the cancer care continuum, of a patient-centered approach and of a prevention-oriented policy. The ultimate goal is a personalized care of CS, achievable only through a multidisciplinary-guided survivorship care plan, one that replaces the fragmented management of current healthcare systems. Collaboration between oncologists and cardiologists is the pillar of a framework in which primary care providers and other specialists must be engaged and in which familial, social and environmental factors are also taken into account.

Cardiac Interventions in Patients With Active, Advanced Solid and Hematologic Malignancies: JACC: CardioOncology State-of-the-Art Review

Invasive cardiac interventions are recommended to treat ST-segment elevation myocardial infarction, non-ST-segment elevation acute coronary syndromes, multivessel coronary disease, severe symptomatic aortic stenosis, and cardiomyopathy. These recommendations are based on randomized controlled trials that historically included few individuals with active, advanced malignancies. Advanced malignancies represent a significant competing risk for mortality, and there is limited evidence to inform the risks and benefits of invasive cardiac interventions in affected patients. We review the benefit conferred by invasive cardiac interventions; the periprocedural considerations; the contemporary survival expectations of patients across several types of active, advanced malignancy; and the literature on cardiovascular interventions in these populations. Our objective is to develop a rational framework to guide clinical recommendations on the use of invasive cardiac interventions in patients with active, advanced cancer.

Long-Term Atherosclerotic Cardiovascular Disease Risk in Patients With Cancer: A Population-Based Study

The long-term risk of incident atherosclerotic cardiovascular diseases (ASCVD) among cancer patients remains incompletely defined. This study aimed to evaluate the long-term ASCVD risk in cancer patients compared with the noncancer population. This was a prospective population-based study using data from the Kailuan cohort, 6204 individuals with newly diagnosed cancer, free of ASCVD, were matched in a 1:1 ratio to noncancer controls for age (±1) and sex, from June 2006 to December 2020. Multivariable competing risk analyses were performed to evaluate the association between cancer diagnosis and risk of incident ASCVD events (including myocardial infarction, ischemic stroke, heart failure, and revascularization with coronary artery bypass graft surgery or percutaneous coronary intervention). During a median follow-up of 5.3 (1.7, 9.7) years, 1019 incident ASCVD events were observed. Compared to participants without cancer, there was a similar risk for incident ASCVD events among cancer patients within the first few years after cancer diagnosis, and the risk declined over time. Overall, cancer patients showed lower risks of incident ASCVD compared to the noncancer patients over the long term, with a hazard ratio (95% confidence interval) of 0.52 (0.45-0.60) for composite ASCVD events, 0.43 (0.35-0.53) for ischemic stroke, 0.63 (0.42-0.95) for myocardial infarction, 0.63 (0.48-0.83) for heart failure, and 0.82 (0.60-1.11) for coronary revascularization. Baseline level of low-density lipoprotein cholesterol, fasting blood glucose, blood pressure, and high-sensitivity C-reactive protein could independently predict the incident ASCVD among the study population. Subgroup analyses according to cancer types revealed a significantly lower risk of ASCVD events among patients with digestive cancer or respiratory cancer compared with noncancer controls, but not for urologic or genital cancer. Multiple sensitivity analyses yielded similar results to the primary analysis. Long-term ASCVD risk among cancer survivors is not increased compared with the noncancer individuals, probably driven by a favorable profile of baseline risk factor in cancer population.

Sociodemographic and Health Correlates of Multiple Health Behavior Adherence among Cancer Survivors: A Latent Class Analysis

The study aimed to (a) assess current levels of adherence to the National Comprehensive Cancer Network's multiple health behavior guidelines and (b) identify characteristics of cancer survivors associated with different adherence levels. Cancer survivors (N = 661) were identified through the state registry and completed questionnaires. Latent class analysis (LCA) was used to identify patterns of adherence. Associations between predictors with the latent classes were reported as risk ratios. LCA identified three classes: lower- (39.6%), moderate- (52.0%), and high-risk lifestyle (8.3%). Participants in the lower-risk lifestyle class had the highest probability of meeting most of the multiple health behavior guidelines compared to participants in the high-risk lifestyle class. Characteristics associated with membership in the moderate-risk lifestyle class included self-identifying as a race other than Asian/Asian American, being never married, having some college education, and having been diagnosed with later stage colorectal or lung cancer. Those in the high-risk lifestyle class were more likely to be male, never married, have a high school diploma or less, diagnosed with colorectal or lung cancer, and diagnosed with pulmonary comorbidities. Study findings can be used to inform development of future interventions to promote multiple health behavior adherence among higher risk cancer survivors.

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada

BACKGROUND

There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets.

METHODS

Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546).

FINDINGS

There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions.

CONCLUSIONS

Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

Association between pre-existing cardiometabolic comorbidities and the pathological profiles of breast cancer at initial diagnosis: a cross sectional study

The presence of comorbidities has been associated with later stages of breast cancer diagnosis. It is unclear whether biological mechanisms are partly responsible. We examined the association between the presence of pre-existing comorbidities and tumour profile at initial diagnosis with breast cancer. Data for the present analysis were derived from a prior inception cohort study comprising 2,501 multiethnic women, newly diagnosed with breast cancer between 2015 and 2017 in four hospitals across Klang Valley. At the inception of the cohort, medical and drug histories, height, weight and blood pressure were recorded. Blood samples were taken to measure serum lipid and glucose. Modified Charlson Comorbidity Index (CCI) was calculated using data extracted from medical records. The association of CCI as well as specific comorbidities, with pathological breast cancer profile was analysed. Higher comorbidity burden, namely cardiometabolic conditions were associated with unfavourable pathological features including larger tumours, involvement of >9 axillary lymph nodes, distant metastasis and human epidermal growth factor receptor 2 overexpression. These associations remained largely significant following multivariable analyses. Specifically, diabetes mellitus was independently associated with high nodal metastasis burden. Low level of high-density lipoprotein was associated with larger tumours (>5 cm), and distant metastasis. Evidence from this study seems to support the hypothesis that the later stages of breast cancer diagnosis in women with (cardiometabolic) comorbidities may be partially explained by underlying pathophysiological events.

Myocardial Protection and Current Cancer Therapy: Two Opposite Targets with Inevitable Cost

Myocardial protection against ischemia/reperfusion injury (IRI) is mediated by various ligands, activating different cellular signaling cascades. These include classical cytosolic mediators such as cyclic-GMP (c-GMP), various kinases such as Phosphatydilinositol-3- (PI3K), Protein Kinase B (Akt), Mitogen-Activated-Protein- (MAPK) and AMP-activated (AMPK) kinases, transcription factors such as signal transducer and activator of transcription 3 (STAT3) and bioactive molecules such as vascular endothelial growth factor (VEGF). Most of the aforementioned signaling molecules constitute targets of anticancer therapy; as they are also involved in carcinogenesis, most of the current anti-neoplastic drugs lead to concomitant weakening or even complete abrogation of myocardial cell tolerance to ischemic or oxidative stress. Furthermore, many anti-neoplastic drugs may directly induce cardiotoxicity via their pharmacological effects, or indirectly via their cardiovascular side effects. The combination of direct drug cardiotoxicity, indirect cardiovascular side effects and neutralization of the cardioprotective defense mechanisms of the heart by prolonged cancer treatment may induce long-term ventricular dysfunction, or even clinically manifested heart failure. We present a narrative review of three therapeutic interventions, namely VEGF, proteasome and Immune Checkpoint inhibitors, having opposing effects on the same intracellular signal cascades thereby affecting the heart. Moreover, we herein comment on the current guidelines for managing cardiotoxicity in the clinical setting and on the role of cardiovascular confounders in cardiotoxicity.

Cancer therapy's impact on lipid metabolism: Mechanisms and future avenues

Atherosclerotic cardiovascular disease is a growing threat among cancer patients. Not surprisingly, cancer-targeting therapies have been linked to metabolic dysregulation including changes in local and systemic lipid metabolism. Thus, tumor development and cancer therapeutics are intimately linked to cholesterol metabolism and may be a driver of increased cardiovascular morbidity and mortality in this population. Chemotherapeutic agents affect lipid metabolism through diverse mechanisms. In this review, we highlight the mechanistic and clinical evidence linking commonly used cytotoxic therapies with cholesterol metabolism and potential opportunities to limit atherosclerotic risk in this patient population. Better understanding of the link between atherosclerosis, cancer therapy, and cholesterol metabolism may inform optimal lipid therapy for cancer patients and mitigate cardiovascular disease burden.