Cardiovascular Risk and Prostate Cancer Management - Episode 3
Shared insight on the correlation between prostate cancer and cardiovascular disease, with a focus on the attributes that increase a patient’s risk.
John L. Fox, MD, MHA: There is certainly a strong connection between cardiovascular disease [CVD] and prostate cancer. We know that cardiovascular disease is the leading cause of death in men with prostate cancer. I think the real question is, is there an increased risk of cardiovascular disease in men with prostate cancer? There are a number of studies that have demonstrated that men with preexisting cardiovascular disease are at a higher risk of subsequent cardiovascular morbidity and mortality compared to those without disease. In fact, there was a study published in 2020 that showed that two-thirds of men initiating treatment for prostate cancer had preexisting cardiovascular disease or cardiovascular risk factors. So while there’s not a clear causal relationship that indicates that treatment for prostate cancer increases the risk of cardiovascular death, I think there’s circumstantial evidence that suggests that patients treated with GnRH [gonadotropin-releasing hormone] therapies are at increased risk. And it may be that patients who are treated with GnRH agonists are at even higher risk, and we can talk about some of that evidence this morning.
Bhavesh Shah, RPh, BCOP: We definitely have to have this primary care lens when we’re caring for patients, screening patients for prostate cancer, even prevention [and] treatment. I thinkthere needs to be an understanding of what preexisting conditions they have. Essentially, life expectancy plays a huge role in who you treat for prostate cancer. We know that there are several life expectancy tables out there that are used by providers to guide them to understand what the life expectancy of a patient is. If you have a patient who is 75 years old, and their life expectancy is less than 5 years, you’re not going to treat them with anything because there can be more risk versus benefit for patients, depending on the stability of their disease and how fast it’s progressing.
Then you’re also looking at, going back to the life expectancy tables, there is [the] Social Security Administration table that can be used. Also, the World Health Organization has a life table by country that you can use. Then of course, Memorial Sloan Kettering [Cancer Center] has a male life expectancy tool that they have developed. The Memorial Sloan Kettering tool incorporates a lot of factors such as age, the stage of diagnosis, heart disease, if the patient has COPD [chronic obstructive pulmonary disease], asthma, smoking, blood pressure, hypertension, diabetes. All of these factors need to be taken into consideration. That provides you guidance in terms of the life expectancy. Those factors also drive how that patient should be cared for after the diagnosis and treatment of their disease because you need to have strategies for prevention and treatment, especially when we know that cardiovascular disease is probably the biggest culprit in mortality for patients with prostate cancer.
We saw that specifically from the recent literature that was published in the Journal of the National Cancer Institute, which talks about patients not actually dying from prostate cancer, but from cardiovascular disease. It really puts into perspective that we need to start educating our patients early and screening for cardiovascular disease, making sure that there’s lifestyle changes, there’s exercise, and appropriate therapies that are initiated for patients as they’re either starting their journey for prostate cancer or starting treatments related to prostate cancer.
Maria Lopes, MD, MS: The evaluation should be in the context of their age, and other comorbidities, including cardiovascular risk factors. There has been for years a known association between the risk of ADT, androgen deprivation therapy, and cardiovascular risk, such that professional recommendations now call for monitoring for CVD risk in men with prostate cancer. In 2010 and prior to the FDA requirement, the American Heart Association as well as the American Cancer Society, and AUA [American Urological Association] issued a scientific advisory acknowledging increased cardiovascular risk in patients undergoing ADT. With standard acknowledgment, lack of a causal relationship still meant that monitoring for adverse events and mortality should be something that should be carefully watched for.
NCCN [National Comprehensive Cancer Network] guidelines also recommend screening and intervention for the prevention or treatment of CVD in men receiving ADT, based on observed metabolic effects of ADT and the association between ADT and the higher incidence of diabetes and cardiovascular risk. So it’s a risk/benefit trade-off in the context of the standard of care with the benefit that ADT provides, and the importance of education, the importance of risk identification, especially to the extent that many of these men have cardiovascular disease already, and you don’t want to be compounding that. But even in men without significant cardiovascular risks, there may still be an increased risk of cardiac events associated with ADT treatment.
Transcript edited for clarity.