Contributors to CVD Risk in Breast Cancer

The increased risk of CVD among breast cancer survivors has been partly attributed to shared risk factors for breast cancer and CVD, such as hypertension.2

Treatment can also contribute to the increased CVD risk in these patients, noted Ragavendra Baliga, MBBS, MD, a professor of cardiology and director of the cardio-oncology program at The Ohio State University Wexner Medical Center and James Cancer Hospital in Columbus.


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“Breast cancer survivors are exposed to various toxic agents during treatment, which may include cardiotoxic drugs such as doxorubicin and trastuzumab that can cause heart failure,” Dr Baliga said.

A 2012 study of 12,500 patients with breast cancer showed an increased risk of heart failure/cardiomyopathy among patients who received anthracycline treatment (adjusted HR [aHR], 1.40; 95% CI, 1.11-1.76), other chemotherapy (aHR, 1.49; 95% CI, 1.25-1.77), trastuzumab alone (aHR, 4.12; 95% CI, 2.30-7.42), or anthracycline plus trastuzumab (aHR, 7.19; 95% CI, 5.00-10.35).7

Furthermore, unfavorable changes in body composition, such as increased body fat, can occur during and after chemotherapy, Dr Sheng noted. She added that the potential cardiotoxic side effects of radiotherapy are well established.

“Radiotherapy can result in coronary atherosclerosis and accelerated endothelial injury as early as 5 years after exposure among breast cancer survivors who receive left-sided thoracic therapy, and persistence of risk remains for up to 30 years,” Dr Sheng said.

In a 2021 study, researchers examined CVD risk in a sample of 41,526 patients who underwent adjuvant radiation after breast-conserving surgery for the treatment of ductal carcinoma in situ.8 The results showed that left-sided radiotherapy was independently associated with higher CVD mortality risk (sHR, 2.35; 95% CI 1.09-5.10; P =.030) in patients age 50 or younger during the first to second decades after radiation.

CVD Risk Management

Traditional CVD risk factors, including diabetes, hypertension, tobacco use, hyperlipidemia, obesity, and a family history of premature heart disease, along with a previous personal history of coronary heart disease or non-coronary atherosclerosis, may confer a higher risk of CVD events in patients with breast cancer, Dr Sheng explained. 

In a 2020 study of 164 breast cancer survivors, many had a history of hypertension (62.8%) and high cholesterol (50.0%).9 The cohort also included current (8.3%) and former smokers (36.0%), patients with a history of diabetes (23.8%), and patients with a history of congestive heart failure (4.9%).

Another small study suggested that CVD risk is increased among male breast cancer survivors.10 High rates of hypertension (58%) and hyperlipidemia (54%) were observed in a sample of 24 male patients.

According to the researchers, these findings suggest a need for involvement of cardiologists and cardio-oncologists in the treatment of male breast cancer.

Dr Baliga emphasized that surveillance is key in managing CVD risk in breast cancer survivors.

“This requires a vibrant cardio-oncology program that includes a cardiologist, oncologist, pharmacist, breast cancer surgeon, radiation oncologist, cancer survivorship clinic, and exercise physiologist,” he said.

Primary care physicians can also play a role in preventing and treating modifiable risk factors, such as hyperlipidemia and hypertension, whereas patients with a higher CVD risk can be referred to cardiology for CVD prevention strategies, Dr Sheng added.

“Attention to reducing the risk of CVD should be a priority for the long-term care of patients following the diagnosis and treatment of breast cancer,” she said.

Dr Baliga pointed to the need for “better preventive strategies and therapies for heart disease in cancer survivors, as increasing numbers of patients are surviving cancer and succumbing to heart disease.”

References

  1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2021. CA Cancer J Clin. 2021;71(1):7-33. doi:10.3322/caac.21654
  2. Gulati M, Mulvagh SL. The connection between the breast and heart in women: Breast cancer and cardiovascular disease. Clin Cardiol. 2018;41:253-257. doi:10.1002/clc.22886
  3. Patnaik JL, Byers T, DiGuiseppi C, Dabelea D, Denberg TD. Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: A retrospective cohort study. Breast Cancer Res. 2011;13(3):R64. doi:10.1186/bcr2901
  4. Ramin C, Schaeffer ML, Zheng Z, et al. All-cause and cardiovascular disease mortality among breast cancer survivors in CLUE II, a long-standing community-based cohort. J Natl Cancer Inst. 2021;113(2):137-145. doi:10.1093/jnci/djaa096
  5. Bradshaw PT, Stevens J, Khankari N, Teitelbaum SL, Neugut AI, Gammon MD. Cardiovascular disease mortality among breast cancer survivorsEpidemiology. 2016;27(1):6-13. doi:10.1097/EDE.0000000000000394
  6. Mery B, Fouilloux A, Rowinski E, et al. Cardiovascular disease events within 5 years after a diagnosis of breast cancer. BMC Cancer. 2020;20(1):337. doi:10.1186/s12885-020-06838-w
  7. Bowles EJ, Wellman R, Feigelson HS, et al. Risk of heart failure in breast cancer patients after anthracycline and trastuzumab treatment: A retrospective cohort study. J Natl Cancer Inst. 2012;104:1293-1305. doi:10.1093/jnci/djs317
  8. Lim YJ, Koh J. Heart-related mortality after postoperative breast irradiation in patients with ductal carcinoma in situ in the contemporary radiotherapy era. Sci Rep. 2021;11(1):2790. doi:10.1038/s41598-021-82263-8
  9. Coughlin SS, Ayyala D, Majeed B, Cortes L, Kapuku G. Cardiovascular disease among breast cancer survivors. Cardiovasc Disord Med. 2020;2(1). doi:10.31487/j.cdm.2020.01.01
  10. Male breast cancer patients face high prevalence of CV disease risk factors. News Release. American College of Cardiology. Published January 25, 2021. Accessed December 2, 2021. https://www.acc.org/latest-in-cardiology/articles/2021/01/25/16/11/male-breast-cancer-patients-face-high-prevalence-of-cv-disease-risk-factors