Cardiovascular disease events within 5 years after a diagnosis of breast cancer

Effectiveness of aerobic exercise intervention on cardiovascular disease risk in female breast cancer: a systematic review with meta-analyses

BACKGROUND

Cardiovascular disease (CVD) has become the leading cause of competitive mortality in female breast cancer (BC). Regular aerobic exercise (AE) has been widely accepted as an effective intervention to reduce cardiovascular risk in a variety of different clinical conditions. This study is aimed at evaluating the efficacy and safety of AE on cardiovascular risk factors in female BC and assessing the quality of the synthesized evidence.

METHODS

We searched five English databases (Cochrane Library, PubMed, Embase, Scopus, and Web of Science) from inception to January 2023. Randomized controlled trials (RCTs) and cohort trials studying the effects of AE intervention on cardiovascular disease risk in female breast cancer were included. We used Stata 16 for data synthesis, Risk of Bias 2, and the Newcastle-Ottawa Scale for methodological quality evaluation and assessed the certainty of the synthesized evidence in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Forty RCTs and 6 cohort trials involving 44,877 BC patients showed AE reduced the incidence of CVD events by 29.4% [risk ratio (RR) = 0.706, 95% confidence interval (CI) (0.659, 0.757), low certainty] and coronary artery disease events by 36% [RR = 0.640, 95% CI (0.561, 0.729), low certainty]. AE improved LVEF, and reduced weight and hip circumference. The subgroup analysis results showed that nonlinear AE increased VO2max by 5.354 ml·kg·min-1 [mean difference (MD) = 5.354, 95% CI (2.645, 8.062), very low certainty] and reduced fat mass by 4.256 kg [MD = 4.256, 95% CI (-3.839, -0.094), very low certainty]. While linear AE reduced low-density lipoprotein cholesterol (LDL-C) by 8.534 mg/dL [MD = -8.534, 95% CI (-15.511, -1.557), low certainty]. The sensitivity analysis results showed that each trial did not affect the impact index of the highly heterogeneous outcomes.

CONCLUSIONS

Our study indicates that AE has a positive effect in reducing cardiovascular risk factors. The individualization principle of AE deserves more attention in the future. This will provide new ideas to reduce CVD events and improve the quality of life in female BC patients. However, further research on AE in female BC should take into account long-term and well-designed administration to draw definitive conclusions.

[Translation into French and republication of: "Cancer-related arterial thromboembolic events"]

Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.

Causal associations between atrial fibrillation and breast cancer: A bidirectional Mendelian randomization analysis

BACKGROUND

Previous observational studies indicated that atrial fibrillation may increase the risk of breast cancer. Following a breast cancer diagnosis, the chance of developing atrial fibrillation may increase as well. However, it is uncertain whether the link is causal or just due to confounding factors.

OBJECTIVE

Using bidirectional Mendelian randomization (MR) analysis, we sought to assess the bidirectional causal relationship between atrial fibrillation and breast cancer from a genetic level.

METHODS

Large genome-wide association studies yielded summary-level data for atrial fibrillation and breast cancer. The preliminary estimate was inverse variance weighted (IVW) under a random model. MR-Egger, weighted median, simple mode, weighted mode, and multivariable MR (adjusting body mass index, smoking, and alcohol drinking) were performed as sensitivity analyses.

RESULTS

Genetically predicted atrial fibrillation presented no statistically significant association with overall breast cancer (odds ratio [OR] = 1.00; 95% confidence interval [CI]: 0.97-1.04; p = 0.79), estrogen receptor (ER) + (OR = 1.00; 95% CI: 0.96-1.03; p = 0.89) or ER- subtypes (OR = 1.00; 95% CI: 0.97-1.04; p = 0.89). Similarly, genetically predicted overall breast cancer (OR = 1.01; 95% CI: 0.98-1.04; p = 0.37), ER+ (OR = 1.02; 95% CI: 0.99-1.05; p = 0.16) or ER- (OR = 0.98; 95% CI: 0.93-1.02; p = 0.32) subtypes had no causal effect on atrial fibrillation. Sensitivity analyses yielded similar results. Individual single nucleotide polymorphism had little effect on the total estimate. We did not observe any evidence of horizontal pleiotropy.

CONCLUSIONS

Our bidirectional MR studies revealed that there may be no causal links between atrial fibrillation and breast cancer.

Cancer-related arterial thromboembolic events

Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.

The association between cardiovascular disease and breast and gynecologic cancers among black female patients

INTRODUCTION

Little is known about whether a breast or gynecologic cancer diagnosis increases long-term cardiovascular disease (CVD) risk among Black females. The purpose of this study was to determine whether a breast or gynecologic cancer diagnosis is associated with CVD risk and identify determinants of subsequent CVD risk among Black females with an incident breast or gynecologic cancer diagnosis.

METHODS

Using the Southern Community Cohort Study data from 2002-2016, this study was designed to analyze CVD incidence among Black females without cancer or CVD at enrollment. Cox proportional hazards regression models with or without covariates were used to explore the relationship between a breast or gynecologic cancer diagnosis and CVD risk among women without cancer as well as without CVD at enrollment (N=11,486). In addition, Cox proportional hazards regression models, excluding those who developed CVD before breast and gynecologic cancer diagnosis and those with other types of cancers, were used to assess determinants of CVD risk among breast and gynecologic cancer survivors.

RESULTS

Of 11,486 Black females, 531 developed a breast or gynecological cancer (4.6%) over a median follow-up of 140 months (interquartile range: 123-159 months). Compared to women without cancer, women with a breast or gynecological cancers had greater than 20% higher risk of incident CVD during the follow-up period. Without adjusting for covariates, positive association between CVD risk and breast cancer was observed (hazard ratio (HR) = 1.24; 95% confidence interval (CI) = 1.11 - 1.39; p < 0.001); as well as between CVD risk and a gynecological cancer (HR = 1.23; 95% CI = 1.03 - 1.46; p = 0.021). Yet, after adjusting for covariates, CVD risk was only significantly associated with breast cancer (p = 0.001) but not gynecologic cancer. In cancer case-only analyses, CVD risk was significantly increasing with age (p < 0.05).

CONCLUSIONS

Like study populations of predominantly White females, our results suggest that, adjusting for covariates, Black females possess a higher risk of CVD following a breast cancer diagnosis compared to women who did not develop breast cancer. Our results suggest a need for active CVD surveillance in the cancer survivorship phase.

Early Echocardiography and ECG Changes Following Radiotherapy in Patients with Stage II-III HER2-Positive Breast Cancer Treated with Anthracycline-Based Chemotherapy with or without Trastuzumab-Based Therapy

BACKGROUND Cardiotoxicity from radiotherapy and anti-cancer therapies have been reported in patients with breast cancer. This study aimed to investigate the early echocardiography and ECG changes following radiotherapy in 68 patients ages 30-78 years with stages II-III HER2-positive breast cancer treated with anthracycline-based chemotherapy with or without trastuzumab-based therapy from 2015 to 2021. MATERIAL AND METHODS We analyzed data of 68 breast cancer patients aged 30-78 years, predominantly in AJCC stages II-III (61) and HER2-positive (58), treated and monitored from 2015 to 2021. Cardiac function was assessed using echo- and electrocardiography. We employed univariate logistic models to gauge associations between pre-existing cardiac conditions, treatment modalities, and changes in cardiac function. RESULTS A decrease in the left ventricle ejection fraction (EF) by >5% was associated with heart doses >49.3 Gy and with maximum and average doses to the left anterior descending artery (LAD) exceeding 46.9 Gy and 32.7 Gy, respectively. An EF drop of ≥10% was correlated with anti-HER2 therapy, pre-existing ECG changes, and the onset of conditions in the left ventricle, major vessels, and valves. Conditions were exacerbated in patients with prior echocardiographic abnormalities, while some emerged concurrent with the EF decline. CONCLUSIONS This research emphasizes the importance of personalized heart monitoring and care for breast cancer patients undergoing multimodal therapies. Significant and potentially irreversible EF declines can result from radiation and anti-HER2 treatments.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Atrial fibrillation in cancer survivors - a systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is a common cardiac complication during cancer treatment. It is unclear if cancer survivors have increased AF risk when compared to the population. AF screening is now recommended in patients ≥65 years, however there are no specific recommendations in the oncology population. We sought to compare the AF detection rate of cancer survivors compared to the general population.

METHODS

We searched the Pubmed, Embase and Web of Science databases using search terms related to AF and cancer mapped to subject headings. We included English language studies, limited to adults > 18 years who were > 12 months post completion of cancer treatment. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to assess for potential causes for study heterogeneity.

RESULTS

Sixteen studies were included in the study. The combined AF detection rate amongst all the studies was 4.7% (95% C.I 4.0-5.4%), which equated to a combined annualised AF rate of 0.7% (95% C.I 0.1-0.98%). There was significant heterogeneity between studies (I² = 99.8%, p < 0.001). In the breast cancer cohort (n = 6 studies), the combined annualised AF rate was 0.9% (95% C.I 0.1-2.3%), with significant heterogeneity (I² = 99.9%, p < 0.001).

CONCLUSION

Whilst the results should be interpreted with caution due to study heterogeneity, AF rates in patients with cancer survival >12 months were not significantly increased compared to the general population.

STUDY REGISTRATION

Open Science Framework - DOI: https://doi.org/10.17605/OSF.IO/APSYG .

Atrial fibrillation and breast cancer—Vicious twins? A systematic review and meta-analysis

Background

Epidemiological studies suggest a bidirectional association between atrial fibrillation and breast cancer. This study aimed to conduct a meta-analysis to elucidate the prevalence of atrial fibrillation among breast cancer patients, and the bidirectional association between atrial fibrillation and breast cancer.

Methods

PubMed, the Cochrane Library, and Embase were searched to identify studies reporting the prevalence, incidence, and bidirectional association between atrial fibrillation and breast cancer. The study was registered with PROSPERO (CRD42022313251). Levels of evidence and recommendations were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

Twenty-three studies (17 retrospective cohort studies, 5 case-control studies and 1 cross-sectional study) involving 8,537,551 participants were included. Among patients with breast cancer, the prevalence of atrial fibrillation was 3% (11 studies; 95% CI: 0.6 to 7.1%) and the incidence was 2.7% (6 studies; 95% CI: 1.1 to 4.9%). Breast cancer was associated with increased risk of atrial fibrillation (5 studies; hazard ratio [HR]: 1.43, 95% CI: 1.12 to 1.82, I2 = 98%). Atrial fibrillation was also significantly associated elevated risk of breast cancer (5 studies HR: 1.18, 95% CI: 1.14 to 1.22, I2 = 0%). Grade assessment shown low certainty of the evidence for the risk of atrial fibrillation and moderate certainty of the evidence for the risk of breast cancer.

Conclusion

Atrial fibrillation is not uncommon in patients with breast cancer and vice versa. There is a bidirectional association between atrial fibrillation (low certainty) and breast cancer (moderate certainty).

Relative Risk of Cardiovascular Mortality in Breast Cancer Patients: A Population-Based Study

Aims

To investigate the risk of cardiovascular disease (CVD) mortality in breast cancer patients compared with the general female population.

Methods

Data was retrieved from the Surveillance, Epidemiology, and End Results database. 924,439 female breast cancer patients who were at the age of follow-up ≥ 30 years and diagnosed during 1990-2016 as well as the aggregated general female population in the US were included. Using multivariable Poisson regression, we calculated incidence rate ratios (IRRs) of CVD mortality among female breast cancer patients compared with the female population.

Results

The risk of CVD mortality was mildly increased among breast cancer patients at the age of follow-up 30-64 years (IRR 1.06, 95% confidence interval [CI] 1.03-1.10) compared with the general population. This growth of risk reached its peak within the first month after diagnosis (IRR 3.33, 95% CI 2.84-3.91) and was mainly activated by diseases of the heart (IRR 1.11, 95% CI 1.07-1.15). The elevation was greatest in survivors at the age of follow up 30-34 years (IRR 3.50, 95% CI 1.75-7.01).

Conclusions

Clinicians should provide risk mitigation strategies with early monitoring of CVD mortality for breast cancer survivors, especially those who were young or with aggressive tumor stage.

Cardiovascular Diseases Following Breast Cancer: Towards a Case-by-Case Assessment Through a Prediction Risk Score Model in 943 Patients

OBJECTIVES

To identify patients at high risk of developing cardiovascular disease through the identification of risk factors among a large population of breast cancer women and to assess the performance of Abdel-Qadir risk prediction model score.

MATERIALS AND METHODS

The medical records and baseline characteristics of all patients/tumors diagnosed with breast cancer from 2010 to 2011 in a French comprehensive cancer center were collected. Cardiovascular events were defined as arterial and cardiac events, atrial fibrillation and venous thromboembolism occurring during the 5-year follow-up. Abdel-Qadir multivariable prediction model for major adverse cardiovascular events were used with the concordance index (c-index) score to assess calibration by comparing predicted risks to observed probabilities.

RESULTS

Among the 943 breast cancer patients included, 83 patients (8.8%) presented with at least one cardiovascular event, leading to a cumulative incidence of 0.07 at 5 years (95% confidence interval [CI], 0.055-0.088). The cumulative incidence of atrial fibrillation at 5 years was 0.01 (95% CI, 0.005-0.018). Factors associated with the occurrence of cardiovascular events were pre-existing cardiovascular diseases including high blood pressure (hazard ratio [HR]=1.78, 95% CI=1.07-2.97, P=0.028), acute coronary syndrome (HR=5.28, 95% CI: 2.16-12.88, P<0.05) and grade 3 Scarff-Blool-Richardson (HR=1.95, 95% CI: 1.21-3.15, P=0.006). With a c-index inferior to 0.7, the Abdel-Qadir score was not fully validated in our population.

CONCLUSION

These findings call for the assessment of the performance of risk prediction models such as Abdel-Qadir score coupled with other factors such as Scarff Bloom and Richardson grading in order to identify patients at high risk of experiencing cardiotoxicity.