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Heart failure patients at increased risk of cancer and cancer-related mortality

28th January 2022

Heart failure (HF) patients have a higher risk of cancer and cancer-related mortality compared to matched-controls according to research by a team from the Cardiovascular Disease Unit, Genoa, Italy.

There is emerging evidence that the incidence of cancer is higher among those with cardiovascular disease and heart failure and this latter group frequently die from cancer. In fact, research has uncovered the increased risk of cancer among HF patients, persists beyond the first year after their HF diagnosis and that their prognosis is worse compared to non-heart failure patients with cancer. Despite this purported association, other work among 28,341 Physicians’ Health Study participants, has shown that HF is not associated with an increased risk of cancer among male physicians. It has also been suggested that while heart failure patients did have a slightly increased risk of various cancer subtypes, these increased risks were largely drive by comorbidities.

Given this potential uncertainty over the HF-cancer association, the Italian team attempted to provide greater clarity by undertaking a retrospective cohort study of healthcare records in Puglia, a region of southern Italy. They included patients aged 50 years and older, diagnosed with heart failure but without a history of cancer in the three years prior to their inclusion in the analysis. The team included a control group without HF who were matched on age and sex. The primary outcomes of the study were cancer incidence as well as mortality. In an effort to examine whether HF severity influenced the study outcomes, the researchers also explored patients use of doses in excess of 80 mg/day of furosemide and equivalents for longer than 30 days in the year before the index date.

Heart failure patients and cancer

A total of 104,020 HF patients with a mean age of 76 years were matched to an equal number of control patients. The researchers identified a total of 12,036 new diagnoses of cancer in HF patients and 7,045 in controls after a median follow-up period of 5 years. This gave an incidence cancer rate of 21.36 per 1000 person-years among those with HF and 12.42 in the control arm (Hazard ratio, HR = 1.76, 95% CI 1.71 – 1.81).

The cancer mortality rate was also higher among HF patients compared with controls (HR = 4.11, 95% CI 3.86 – 4.38). This difference was also seen among HF patients aged less than 70 years (HR = 1.66, 95% CI 1.58 – 1.75) and in those over 80 years of age (HR = 2.07).

High dose loop diuretics also showed an important effect with a higher cancer incidence (HR = 1.11, 95% CI 1.03 – 1.21) and cancer-related mortality (HR = 1.35).

The authors concluded that HF patients had both a higher incidence of cancer and cancer mortality than matched controls and speculated that given that the risk was elevated among those with high dose loop diuretics, it was possible that the overall cancer risks were potentially higher in those with decompensated, i.e., more severe HF.

Citation

Bertero E et al. Cancer Incidence and Mortality According to Pre-Existing Heart Failure in a Community-Based Cohort JACC CardioOncology 2022

Aspirin use associated with improved survival but only for bladder and breast cancer

18th January 2021

The protective effects of aspirin in older patients with a range of different cancers has been poorly studied prompting researchers to examine the benefits for a range of different cancers.

The risk-benefit ratio for the use of aspirin in older adults is still unclear though some secondary analyses of randomised trials have indicated that aspirin can reduce the incidence and mortality due to colorectal cancer. Given this uncertainty, a team from the Division of Cancer Prevention, National Cancer Institute, Maryland, US, decided to focus their investigation on a post hoc analysis of older individuals in the prostate, lung, colorectal and ovarian cancer screening trial (PLCO).

PLCO was a large trial to determine the effects of screening on cancer-related mortality and secondary endpoints in people aged 55 to 74 years of age. The researchers limited their analysis to individuals at least 65 years of age after enrolment and whose baseline questionnaire contained information on aspirin use. Individuals who had a history of any of the cancers studied were excluded. The use of aspirin was then categorised as either less than or more than three-times/week. The aim of the study was to evaluate whether use of aspirin had an impact on the incidence and survival from bladder, breast, oesophageal, gastric, pancreatic and uterine cancers among individuals 65 years of age and older. The original PLCO data collection was completed in 2009 after 13 years of follow-up but for the current study, data collection continued until 2014, among individuals who consented to further follow-up or 2009 in those unwilling to be followed.

Findings
The eligible study population included 139,896 individuals with a mean age at baseline of 66.4 years (51.4% female). A total of 32,580 incident cancers were recorded during the follow-up period. The use of aspirin at least three times per week not associated with the incident risk of any of the included cancers. However, the researchers did find that after adjustment for co-morbidities, aspirin use (i.e., at least three times per week) was associated with a significantly increased survival compared to no use of the drug for bladder (hazard ratio, HR = 0.67, 95% CI 0.51–0.88, p = 0.003) and breast cancer (HR = 0.75, 95% CI 0.59–0.96, p = 0.02) only. In addition, any use of aspirin was also associated with a reduced risk of death from both bladder (HR = 0.75, 95% CI 0.58 – 0.98) and breast cancer (HR = 0.79, 95% CI 0.63–0.99) but again, not for any of the other cancers.

Unfortunately, the authors were unable to account for their findings and concluded that further work is needed to consider the relative benefits and harms associated with longterm use of aspirin.

Citation
Loomans-Kropps HA, Pinksky P, Umar A. Evaluation of aspirin use with cancer incidence and survival among older adults in the prostate, lung, colorectal, and ovarian cancer screening trial. JAMA Netw Open 2021