Susannah Stanway

Long term adjuvant endocrine therapy and risk of cardiovascular disease in female breast cancer survivors: systematic review

Abstract Objective To investigate the effect of endocrine therapies on a wide range of specific clinical cardiovascular disease outcomes in women with a history of non-metastatic breast cancer. Design Systematic review and meta-analysis of randomised controlled trials and observational studies. Data sources Medline and Embase up until June 2018. Eligibility criteria for selecting studies Studies were included if they investigated the risk of a specific cardiovascular disease outcome associated with use of either tamoxifen or an aromatase inhibitor, or compared the two treatments, in women with a history of non-metastatic breast cancer. Appraisal and data extraction Relevant studies were originally identified and results extracted by one researcher, with a full replication of the study identification process by a combination of two other researchers. The Cochrane Collaboration’s tool for assessing risk of bias was used to assess risk of bias in randomised controlled trials, and this tool was adapted to assess risk of bias in observational studies. Results 26 studies were identified, with results for seven specific cardiovascular disease outcomes (venous thromboembolism, myocardial infarction, stroke, angina, heart failure, arrhythmia, and peripheral vascular disease). Results suggested an increased risk of venous thromboembolism in tamoxifen users compared with both non-users and aromatase inhibitor users. Results were also consistent with a higher risk of the vascular diseases myocardial infarction and angina in aromatase inhibitor users compared with tamoxifen users, but there was also a suggestion that this may be partly driven by a protective effect of tamoxifen on these outcomes. Data were limited, and evidence was generally inconsistent for all other cardiovascular disease outcomes. Conclusion This review has collated substantial randomised controlled trial and observational evidence on the effect of endocrine therapies on several specific cardiovascular disease outcomes including venous thromboembolism and myocardial infarction, progressing knowledge. Although the choice of aromatase inhibitor or tamoxifen will primarily be based on the effectiveness against the recurrence of breast cancer, this review shows that the individual patient’s risk of venous or arterial vascular disease should be an important secondary consideration. Systematic review registration Prospero CRD42017065944.

Statin use in cancer survivors versus the general population: cohort study using primary care data from the UK clinical practice research datalink

BackgroundCancer survivors may be at increased risk of cardiovascular diseases, but little is known about whether prescribing guidelines for the primary prevention of cardiovascular disease are adequately implemented in these patients. We compared levels of statin initiation and cessation among cancer survivors compared to the general population to determine differences in uptake of pharmaceutical cardiovascular risk prevention measures in these groups.MethodsThe study population included individuals aged ≥40 during 2005–13 within the UK Clinical Practice Research Datalink primary care database. Within this population we identified cancer survivors who were alive and under follow-up at least 1 year after diagnosis, and controls with no cancer history. Follow-up time prior to cancer diagnosis was included in the control cohort. Using logistic regression, we compared these groups with respect to uptake of statins within 1 month of a first high recorded cardiovascular risk score. Then, we used Cox modelling to compare persistence on statin therapy (time to statin cessation) between cancer survivors and controls from the main study population who had initiated on a statin.ResultsAmong 4202 cancer survivors and 113,035 controls with a record indicating a high cardiovascular risk score, 23.0% and 23.5% respectively initiated a statin within 1 month (adjusted odds ratio 0.98 [91.8–1.05], p = 0.626). Cancer survivors appeared more likely to discontinue statin treatment than controls (adjusted hazard ratio 1.07 [1.01–1.12], p = 0.02). This greater risk of discontinuing was only evident after the first year of therapy (p-interaction < 0.001).InterpretationAlthough cardiovascular risk is thought to be higher in cancer survivors compared to the general population, cancer survivors were no more likely to receive statins, and marginally more likely to cease long-term therapy, than general population controls. There may be an opportunity to mitigate the suspected higher cardiovascular risk in the growing population of cancer survivors by improving uptake of lipid-lowering treatment and persistence on therapy.

Second Primary Neoplasms Following a Diagnosis of Breast Cancer

Many women diagnosed with early breast cancer will be cured and survive for many years after their initial diagnosis. Therefore it is important to take into account the risk of the development of new primary malignancies in such patients. Patients may be predisposed to develop new primary cancers as a result of genetic predisposition, environmental factors, or as a result of the adjuvant therapies used to treat early breast cancer. Treatment-related second primary cancers include an increased risk of breast and lung cancers following adjuvant radiotherapy, hematological malignancies following adjuvant chemotherapy, and endometrial cancer following tamoxifen. As a result of confounding factors the increased risk of these events differs between analyses, but the overall absolute risk of treatment-related second primary cancers remains low. Nonetheless it is important that patients are informed of these risks, modifiable risk factors are addressed and measures to minimize risks are undertaken, particularly when considering adjuvant therapies in women at low risks of recurrence.

Cardiotoxicity in Breast Cancer Survivors

Breast cancer is the most common cancer in females globally and, with earlier detection and improvements in treatment, increasing numbers of women are surviving and living free of disease for many decades. However, several breast cancer treatment modalities are associated with a significant risk of toxicity to the heart both at the time of treatment and many years afterwards. This chapter will discuss the risks, pathogenesis, diagnosis and treatment of cardiotoxicity secondary to Anthracyclines, Trastuzumab and radiotherapy, in breast cancer patients. Approaches to risk stratification, surveillance, prevention and treatment of cardiotoxicity in these patients will also be discussed.

Fifteen-year experience of all patients (pts) with small bowel adenocarcinoma (SBA), treated in a specialized gastrointestinal (GI) oncology unit: Royal Marsden (RM) experience.

316 Background: Small bowel adenocarcinoma (SBA) is a rare tumour with poor prognosis. There is paucity of published literature due to rarity of disease; we conducted this retrospective study to determine the clinical course and outcome along with prognostic factors in both early and later stage SBA. Methods: Clinical characteristics and outcomes of all pts treated consecutively in the GI Unit RM, 1996-2011 were recorded. The study endpoints were relapse free survival (RFS), progression free survival (PFS), and overall survival (OS), in early stage pts (G1) and in pts with advanced disease (presentation or relapse with un-resectable disease=G2). In G2 response rate (RR) to chemotherapy was determined. In both groups association to baseline prognostic factors were sought by performing Cox regression univariate analysis (UVA). Results: Eighty four pts with SBA were treated 1996-2011. A total of 48 presented with early stage disease (G1). In G1 (58.3% males; mean age, 57 years), 44/48 pts underwent R0 resect...