Cancer Survivors Need Targeted Interventions When They Return to Primary Care

Better therapeutic options have allowed more patients than ever before to survive a cancer diagnosis, swelling the population of aging cancer survivors at risk for cardiovascular disease (CVD).

It’s estimated that 26 million cancer survivors will be living in the US by 2040, and 73% will be 65 years or older, according to SEER data.

People who survive cancer have been shown to have an elevated risk of CVD death compared with the general US population and, for some, CVD mortality risk outstrips the risk of dying from their index cancer.

Cardiotoxicity from cancer therapies can play a role, but shared social and clinical risk factors as well as mechanisms, such as inflammation, link the development of both diseases, observed Anita Deswal, MD, MBBS, MPH, professor and chair of cardiology, University of Texas MD Anderson Cancer Center, Houston, and chair of the American College of Cardiology (ACC) Cardio-Oncology Section.

“We need to manage the coexisting comorbidities so the patient can get cancer therapy and second, manage the risk factors so that after they survive cancer, they can actually have good cardiovascular health,” Dr. Deswal told MedCentral.

CVD Prevention Needs to Be Aggressive in People Who Survive Cancer

Cardiovascular disease risk should be assessed before, during, and after cancer treatment. In addition, patients with high CVD risk, pre-existing CVD, or receiving high CVD-risk cancer therapy should be referred to cardio-oncology or cardiology, said Dr. Deswal. Primary care providers play a key role in screening and aggressive management of longer-term cardiovascular and cardiometabolic conditions in people who survive cancer.

A 2022 study of 951 patients at least 2 years post-cancer therapy found that nearly all (91.6%) had at least one annual primary care visit and most (54.6%) had a primary care physician as their dominant provider.

It’s important for primary care physicians to know that cancer survivors have a higher prevalence of CVD risk factors such as diabetes, hypertension, and obesity, and to treat more aggressively in terms of prevention because of the higher risk of long-term complications, Dr. Deswal said.

“If there’s one take-home message: scrutinize the cancer survivor even more carefully for the standard cardiovascular risk factors,” she said.

Primary Care Physicians Can Get Cancer Survivors Back into Routine Care

“Primary care providers are a key partner in taking care of patients who have had a cancer diagnosis. They don’t always feel like that but they are,” said medical oncologist Anne Blaes, MD, professor, division of hematology, oncology and transplantation, University of Minnesota, and director of the screening, prevention, etiology, and cancer survivorship (SPECS) program, Masonic Cancer Center, both in Minneapolis.

“The things they know really well – like immunizations, prevention, and screening – I would say are super important because patients may be seeing a doctor frequently but they’ve kind of gotten behind on a lot of the other healthcare maintenance,” she said.

It’s important at the time of diagnosis but becomes even more important after therapy for an internist to also think about the ABCDEs, Dr. Blaes suggested. This includes thinking through whether the patient:

• A – needs aspirin

• B – has good blood pressure control

• C – is smoking cigarettes and their cardiac function

• D – how they’re doing in terms of their diet and diabetes

• E – whether they exercise

“During treatment, I think we undermanage hypertension,” Dr. Blaes said. “Lots of people come into our clinic – and this is actually probably more of a reflection on oncology – but we’re all worried they’re going to have nausea or diarrhea and drop their blood pressure but in reality, many of them are walking around with blood pressures that are higher than they should be.”

During cancer treatment many patients also go off their other medications, despite their long-term risk for CVD, especially if they’ve had drug exposures or were treated as an adolescent or young adult up through age 40, she observed.

“They go off their blood pressure medicines or their cholesterol medications and they don’t get restarted,” Blaes said. “That’s a huge opportunity for us to work with internal medicine and primary care to just say, ‘If somebody’s done with cancer treatment, just evaluate all of that.’”

“The other thing I would say – and this is on all of us – is to figure out how to help patients stay active,” she said. “That’s important for a lot of reasons.”

Exercise is known to help reduce heart risk but there’s also literature that it helps reduce cancer recurrence risk as well. People also feel better, mental health and quality of life is better during treatment but also after treatment, Dr. Blaes said. “So, figuring out how we work with our primary care doctors, our community partners to get patients moving, I think, is really important for long-term health.”

What to Monitor in Patients on Targeted Cancer Therapies

Both Dr. Blaes and Dr. Deswal observed that primary care and internal medicine specialists are familiar with the increased risk of cardiomyopathy and heart failure with anthracyclines and trastuzumab-based therapies. But cancer treatment has evolved, and cardiotoxicity now leads to the gamut of CVD, in addition to heart failure.

In breast cancer, for example, there are medications now that can cause hyperglycemia: one is the P13K inhibitor alpelisib (Piqray) and another, the recently approved first-in-class AKT inhibitor capivasertib (Truqap), Dr. Blaes said. “I usually call the internist and just tell them, ‘I need you to see the patient within the week so that we can collaborate’ because I know it’s going to make the blood sugars go up.”

Some of the targeted drugs, such as tyrosine kinase inhibitors, can cause hypertension, while some studies suggest there’s accelerated atherosclerosis with immunotherapies, Dr. Blaes noted.

“The other thing with immunotherapy I would watch for are endocrinopathies. So, things like hypothyroidism or affecting cortisol levels, which some literature would suggest can happen after they’re done with treatment, usually within a couple months but not necessarily on treatment,” she said.

Although “it’s a really exciting time with advances in cell therapy, we really don’t know if there’s long-term risk with them at all,” she observed.

Disclosures: Dr. Deswal and Dr. Blaes reported no relevant financial relationships.