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Cardiovascular Disease Risk Among Cancer Survivors
Quick Takes
- This is a substudy of the ARIC (Atherosclerosis Risk in Communities) prospective cohort examining the association between cancer survivorship and incident cardiovascular disease (CVD).
- Cancer survivors had a 37% higher risk of incident CVD, 52% higher risk of heart failure, and less strong associations with stroke and atherosclerotic disease.
- The association between cancer survivorship and incident CVD was only minimally attenuated by accounting for traditional CV risk factors, suggesting nontraditional factors yet to be characterized such as inflammation or oxidative stress likely contribute to the bulk of the association.
Study Questions:
What is the risk of cardiovascular disease (CVD) in cancer survivors?
Methods:
This is a study leveraging the prospective community-based ARIC (Atherosclerosis Risk in Communities) cohort in order to estimate the association between cancer survivorship and incident CVD and its subtypes. ARIC included participants aged 45-64 years at enrollment who were followed prospectively for incident CVD and underwent study examinations every 3 years (latest in 2020). A total of 12,421 participants with data linked to cancer registries were included in this substudy of ARIC. Cancer survivors were defined as those with a diagnosis of an invasive cancer during ARIC follow-up and who were free of CVD at the time of diagnosis. Incident CVD was defined as the composite of incident coronary heart disease (CHD), stroke, or heart failure (HF). These outcomes were examined individually as secondary outcomes.
Results:
There were 12,421 participants included in this analysis, of whom 55% were women, 25% were Black, and the mean age was 54 years. At follow-up (median of 13.6 years), 3,250 had a diagnosis of cancer, and were more likely to be men, older, Black, smokers, and have hypercholesterolemia compared to those who did not develop cancer (n = 9,171). Postmenopausal breast cancer was the most common cancer among women (35%), while prostate cancer was the most common cancer among men (40%). At a median follow-up of 14 years post-cancer diagnosis, there were 3,723 incident CVD events: 1,824 cases of CHD, 1,162 strokes, and 2,665 HF events. After adjusting for multiple confounders, the incidence rate of CVD remained higher among those who developed cancer (17.4; 95% confidence interval [CI], 14.8-20.5) than among those without cancer (11.0; 95% CI, 9.6-12.7), with a 37% increase in risk of CVD. The association was notably stronger in women. Interestingly, cancer survivorship was associated with incident HF and stroke but not CHD. Survivorship from breast, lung, colorectal, hematopoietic, and lymphatic cancer but not prostate cancer was independently associated with CVD.
Conclusions:
The authors concluded that cancer survivorship is independently associated with incident CVD.
Perspective:
While the association between cancer and CVD is now well established, many of the studies which revealed that association have been limited by their retrospective nature and use of various surrogate data points to infer CVD or cancer-related risk factors and treatments. This study addresses many of the aforementioned limitations and confirms the association between CVD limitations, while introducing interesting nuances. Notably, the risk of incident CVD and CVD subtypes varied by primary cancer type, with significant risk associations for breast, lung, colorectal, and hematopoietic and lymphatic cancers, but no significant associations for prostate cancer. This finding is interesting given the previously described associations between prostate cancer and its treatments with CVD, but can be explained by the fact that prostate cancer is often managed with active surveillance and the study did not include data on cancer treatment.
Another notable difference is that the prevalence of CVD risk factors reported in this study was not dramatically higher in participants with cancer compared to those without. The authors suggest that this may be because comorbidity assessment was performed directly and prior to the diagnosis of cancer. Adjusting for traditional CVD risk factors only mildly attenuated the association between cancer survivorship and CVD, suggesting that other nontraditional risk factors likely account for the bulk of the association.
The major limitation of this study is the lack of information on cancer staging and treatments—both factors which are likely to have a major impact on the risk of CVD. Nevertheless, this study enshrines the paradigm of cancer being considered as a risk factor for CVD, highlighting the need for proactive screening and preventive strategies in this group of patients.
Clinical Topics: Cardio-Oncology, Cardiovascular Care Team, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Homozygous Familial Hypercholesterolemia, Acute Heart Failure
Keywords: Atherosclerosis, Breast Neoplasms, Cancer Survivors, Cardiotoxicity, Cardiovascular Diseases, Colorectal Neoplasms, Comorbidity, Coronary Disease, Heart Failure, Hypercholesterolemia, Inflammation, Lung Neoplasms, Primary Prevention, Prostatic Neoplasms, Risk Factors, Secondary Prevention, Smokers, Stroke, Survivorship
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