Prostate Cancer: Specialist Referral Improves Heart Risk Management
Introduction
Prostate cancer is one of the most common diseases affecting men, and advances have been made in diagnosis and treatment to help patients survive longer. However, the focus must remain on co-occurring health issues that arise as a consequence of the disease or treatment.
Cardiovascular risk in prostate cancer is an important issue, particularly when a person is undergoing androgen deprivation therapy (ADT). ADT is used to reduce the impact of male hormones on the body by lowering their production in the testes or preventing them from interacting with androgen receptors in other body tissues.
While ADT can be an essential part of prostate cancer treatment, physicians need to take a patient's cardiovascular condition into consideration.
A recent randomized clinical trial in 2,487 patients studied whether routine care from an internist or cardiologist could improve a prostate cancer patient's cardiovascular risk management.
Results indicated a better control of risk factors was found when patients received the care of a specialist, although the intervention was not associated with lower rates of cardiovascular deaths, myocardial infarction, stroke, or heart failure.
While the results are promising, physicians and patients need to remain cautious. Better control of cholesterol levels and improved blood pressure numbers are excellent results, but they do not equate with fewer cardiovascular events.
What Did the Prostate Cancer Cardiovascular Trial Study?
The trial involved 2,487 patients across 55 sites, with patients included in the study based on having been diagnosed within the past year, receiving or about to receive ADT, and/or recently undergoing ADT.
Patients were randomized into two groups.
Usual-Care Patients
The first group consisted of patients who received usual medical care, and these patients' cardiovascular risk was managed according to standard-of-care practices.
Specialist-Referred Patients
The second group of patients received usual care plus a referral to an internist or cardiologist for additional specialist intervention.
The specialist intervention was focused on several cardiovascular (CV) risk factors including blood pressure control, cholesterol management, statin treatment, smoking cessation, healthy eating, and regular physical activity, along with a general CV risk assessment.
A target blood pressure of no higher than 130 mmHg was established, and statin treatment was initiated regardless of a person's cholesterol level.
The study aimed to see whether a more systematic CV risk management approach would improve outcomes for someone with prostate cancer.
Why Cardiovascular Risk Matters in Prostate Cancer
Cancer and cardiovascular disease are two common conditions affecting older people, and many prostate cancer patients are likely to develop one or more cardiovascular conditions since advancing age is a risk factor for both diseases.
The combination of prostate cancer and cardiovascular disease can put a strain on a person, and it is essential for physicians to take a patient's cardiovascular risk into account since androgen deprivation therapy (ADT) can negatively impact blood pressure, cholesterol levels, blood sugar, weight, and other risk factors for cardiovascular disease.
Physicians should, therefore, consider a patient's blood pressure, cholesterol levels, blood sugar, body weight, physical activity, smoke, and existing cardiovascular disease before making treatment decisions for someone with prostate cancer.
Cardiovascular Risk Management Improved the Trial's Main Outcome
After a median of 5.8 years of follow-up, the trial found that patients who received a specialist referral had a more favorable hierarchical composite outcome than patients who received only usual care, with the specialist-referred group having a win ratio of 1.60 (95% CI, 1.42-1.81).
This means that the intervention group (receiving a referral to a specialist) experienced favorable outcomes more often than the control group (receiving only usual care).
However, it is necessary to put these results in context, as the intervention group only exhibited significantly lower risk factor levels for one of the study's outcomes, and better cholesterol control was responsible for most of the observed improvement.
This means the results should not be extrapolated to imply that specialist referral improves survival for prostate cancer.
Cholesterol Levels Were the Most Favorable Outcome
One of the most apparent differences between the two groups involved cholesterol levels, with the intervention group's cholesterol levels being, on average, approximately 12 mg/dL lower than those of the control group at the conclusion of the trial.
This can partially be explained by the fact that statin treatment was encouraged among intervention group members.
Why Statins Are an Important Consideration
Statin drugs are often prescribed for the treatment and prevention of cardiovascular disease, and statin therapy can be an essential part in reducing the risk of several cardiovascular events, including heart attack and stroke.
Statin drugs work by reducing cholesterol levels in the body, and high cholesterol is a well-known risk factor for many cardiovascular conditions.
Cholesterol can accumulate on the walls of arteries and contribute to the development of plaque, gradually narrowing the artery and restricting blood flow.
This means managing cholesterol levels can reduce the risk of many cardiovascular conditions for someone with prostate cancer.
However, statin treatment should be carefully considered for each individual patient since the decision to prescribe the drugs should be based on a person's individual health needs.
Blood Pressure Was Improved, but Not by Much
Another notable finding involved blood pressure, as the intervention group's systolic blood pressure was, on average, 1.8 mmHg lower than that of the control group at the conclusion of the trial.
Target systolic blood pressure for patients in the trial was no higher than 130 mmHg.
The average systolic blood pressure for the intervention group was 131.1 mmHg, compared to 132.9 mmHg for the control group.
Although the difference in average systolic blood pressure between the two groups is relatively small, it still indicates that the intervention had a positive effect on the patients' cardiovascular risk.
The main cause of this improvement was the better control of cholesterol levels, but improved blood pressure was also a contributing factor.
Did Seeing a Cardiologist Prevent Heart Attacks and Strokes?
This is an essential question, and unfortunately, an answer cannot be extrapolated from the findings of this particular clinical trial.
Despite better control of many cardiovascular risk factors, the researchers did not find evidence that specialist referral reduced the risk of cardiovascular death, myocardial infarction, stroke, or heart failure for patients receiving androgen deprivation therapy for prostate cancer.
The subdistribution hazard ratio was 1.08 (95% CI, 0.79-1.49).
What This Means
A hazard ratio close to 1 indicates that there is no significant difference between the two groups being studied for a given outcome.
More importantly, with a confidence interval crossing 1, it was not possible to conclude that specialist referral reduced the risk of any of the aforementioned adverse cardiovascular events with statistical significance.
This means it would not be correct to conclude from this study that specialist referral prevents heart attacks, stroke, or cardiovascular death in prostate cancer.
What Can We Actually Take Away From This Study?
The findings are a good reminder that although better control of risk factors such as cholesterol levels is generally beneficial, researchers and clinicians are ultimately more interested in longer-term outcomes such as the reduction in adverse cardiovascular events, incidence of heart failure, and overall survival.
Cholesterol levels are an important consideration, and the intervention had a positive effect on the average levels of total cholesterol among trial participants.
Better control of blood pressure was also an advantage, and smoking cessation, physical activity, and healthy eating are undeniably beneficial for long-term health.
However, the ultimate question is whether these positive changes translated into clinically significant reductions in adverse cardiovascular events, and the findings were not able to support such a conclusion.
Risk-Reduction Outcomes Versus Major Adverse Cardiovascular Events
Consider the following two outcomes.
Risk-reduction outcome:
A person begins a statin drug regimen and successfully reduces their cholesterol levels.
Clinical outcome:
The same person has a decreased risk of experiencing an adverse cardiovascular event such as a heart attack or stroke.
The first outcome can occur without support for the second being demonstrated within a particular study, and this is particularly important to note in the context of the findings.
Should Every Prostate Cancer Patient See a Cardiologist?
The findings should not be used to suggest that every man with prostate cancer should see a cardiologist for routine cardiovascular risk management.
Instead, the findings reinforce the necessity of a systematic approach to cardiovascular risk management for prostate cancer patients.
There are patients for whom specialist consultation might be more beneficial than others based on their individual health needs.
For instance, a doctor might recommend cardiovascular consultation for a person with severe cardiovascular disease, challenging blood pressure control, complex lipid abnormalities, and other cardiovascular concerns during androgen deprivation therapy.
The decision to consult a specialist should be individualized for each patient.
Primary Care and Cancer Care Remain Important
Cardiologists and internists are not the only professionals who can help reduce a prostate cancer patient's cardiovascular risk.
Primary care doctors, oncologists, urologists, nurses, dieticians, and many other healthcare professionals can also play a part in helping a prostate cancer patient reduce their cardiovascular risk.
The most effective strategy might involve communication and collaboration between the cancer care and cardiovascular care teams.
Lifestyle Measures Are an Important Consideration
Drug treatment is only a part of the cardiovascular risk management equation, and there are lifestyle considerations that can also help improve long-term health outcomes for a prostate cancer patient.
The healthcare team can help develop a nutritious eating plan that reduces the risk of developing additional health problems while a person is undergoing cancer treatment.
A healthy eating plan typically involves eating plenty of vegetables, fruits, and whole grains and limits saturated fats, added sugars, and highly processed foods.
Physical Activity Plays a Role in Health and Wellness
Physical activity can improve a person's cardiovascular health, build muscle, and improve a person's metabolic health.
Patients receiving androgen deprivation therapy should speak with their healthcare team about developing an individualized physical activity plan that takes their current health needs and potential cancer treatment complications into account.
Smoking Cessation Can Improve Cardiovascular Outcomes
Smoking is a major risk factor for developing cardiovascular disease, and the trial specifically included smoking cessation support as a part of the intervention.
Helping patients quit smoking can, therefore, be an important component of reducing cardiovascular risk for a prostate cancer patient.
Metabolic and Weight Management
Maintaining a healthy weight and metabolic health are also important considerations for men undergoing prostate cancer treatment.
Doctors may recommend monitoring a patient's blood glucose, blood pressure, cholesterol levels, and weight during treatment.
What the Findings Mean to Doctors
There are several key take-home points for doctors and clinicians who care for prostate cancer patients.
Firstly, cardiovascular risk should not be overlooked simply because a patient is receiving care for prostate cancer.
Secondly, men who are beginning or receiving androgen deprivation therapy should have their modifiable cardiovascular risk factors regularly assessed.
Thirdly, cholesterol management appears to be an important consideration in reducing a prostate cancer patient's cardiovascular risk.
Finally, clinicians should be aware that better laboratory values do not necessarily indicate reduced cardiovascular risk unless it has been demonstrated within a clinical trial.
What the Findings Mean to Patients
The findings are a powerful reminder for prostate cancer patients that cancer treatment should be considered holistically.
Patients should ask their healthcare team about their cardiovascular risk, including their blood pressure, cholesterol levels, risk of heart disease, smoking, physical activity, diet, blood sugar, weight, and heart and stroke history while undergoing cancer treatment.
Patients undergoing androgen deprivation therapy should specifically ask about the potential impact of the treatment on their cardiovascular and metabolic health.
However, patients should not stop cancer treatment or take any action based on concerns about cardiovascular risk without first speaking with their doctor, as androgen deprivation therapy can be an essential component of prostate cancer treatment for some patients.
Why More Research Is Needed
The clinical trial has an important limitation.
Although the findings indicate that a structured approach to cardiovascular risk management can reduce many cardiovascular risk factors, the findings were not able to indicate whether the observed improvements would ultimately reduce a prostate cancer patient's risk of experiencing a cardiovascular event such as a heart attack or stroke.
Researchers will need to continue investigating the effects of structured cardiovascular risk management in prostate cancer.
Further research might reveal whether long-term follow-up, different interventions, or a more targeted approach will be necessary to observe a reduction in major adverse cardiovascular events among prostate cancer survivors.
A More Targeted Approach Is Likely Necessary
Rather than recommending that every prostate cancer patient see a cardiologist for routine cardiovascular risk assessment, future recommendations might focus on specialist consultation for patients at particularly high cardiovascular risk.
An effective strategy might involve regular cardiovascular risk assessments for prostate cancer patients, aggressive management of cardiovascular risk factors when appropriate, and specialist consultation for patients with complex needs.
This strategy could also involve continued communication between the cancer treatment and cardiovascular treatment teams.
Key Take-Away Points From the Study
The most important findings from the study can be summarized succinctly.
Specialist referral improved cardiovascular risk factor management among prostate cancer patients. Patients receiving specialist care had a more favorable hierarchical composite outcome.
Cholesterol levels were significantly improved by the specialist intervention. Mean cholesterol levels were approximately 12 mg/dL lower in the intervention group.
Statin treatment played a significant role in reducing cholesterol levels. Statin treatment was encouraged in the intervention group regardless of a person's cholesterol level.
Blood pressure was also improved, but the difference was small. Average systolic blood pressure was 131.1 mmHg versus 132.9 mmHg for the intervention and control groups, respectively.
The intervention was not associated with lower rates of major adverse cardiovascular events. The study did not demonstrate a reduction in cardiovascular death, heart attack, stroke, or heart failure.
Routine referral for everyone is not supported by the findings. The findings support a systematic approach to cardiovascular risk management but do not support routine specialist referral for everyone with prostate cancer.
Conclusion
Cardiovascular health is an essential consideration for men who are living with prostate cancer, particularly for patients who are undergoing androgen deprivation therapy.
A randomized clinical trial in 2,487 patients found that adding specialist care to a patient's routine care improved cardiovascular risk factor management.
The greatest improvement was seen in cholesterol levels, with the intervention group's levels being, on average, approximately 12 mg/dL lower than those of the control group at the conclusion of the trial.
Blood pressure was also improved, although the difference was comparatively small.
However, the study did not demonstrate an association between the intervention and a reduced risk of cardiovascular death, heart attack, stroke, or heart failure, and thus the findings should not be extrapolated to suggest that routine specialist referral reduces the risk of cardiovascular events for prostate cancer patients.
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