Almost half of patients with head and neck squamous cell carcinoma (HNSCC) have at least one suboptimally controlled cardiovascular (CV) risk factor, which in turn may be associated with an increased risk for CV events and death, suggests a study among US veterans.
The findings show that “CV risk mitigation is essential to survivorship care” for patients with HNSCC, wrote Lova Sun, from the Perelman School of Medicine at the University of Pennsylvania, and co-authors in JAMA Otolaryngology–Head & Neck Surgery.
Risk mitigation could include low-cost interventions such as lifestyle modifications, prescription of risk-reducing CV medications to control hypertension and diabetes, and stopping smoking, they suggest. In addition, integration of multidisciplinary care with cardio-oncology clinicians could help to ensure appropriate emphasis on CV risk assessment and prevention during and after cancer treatment in this high-risk population.
The retrospective study included data for 35,897 US veterans (median age 63 years, 99% men, 82% White individuals) who were diagnosed with HNSCC between January 2000 and December 2020.
Of these, 83% were listed as current or former smokers, 67% had hypertension, 51% had raised lipid levels, and 22% had diabetes, indicating high levels of CV risk overall.
Although most study participants were taking risk-lowering medications—85%, 73%, and 77% were receiving antihypertensive, lipid-lowering, and glucose-lowering medication, respectively—almost half (48%) had at least one uncontrolled CV risk factor, including 32% with uncontrolled blood pressure, 20% with uncontrolled lipids, and 15% with uncontrolled glucose levels.
After adjusting for potential confounders, the researchers observed that Black participants were a significant 6% more likely to have uncontrolled CV risk factors than White participants, while individuals aged 65 years and over had a significant 7% higher likelihood than their younger counterparts.
Higher T and N stage were associated with a 3% to 15% lower likelihood of having uncontrolled CV risk factors, whereas there was no association with CV risk factor control and the presence of coronary artery disease.
Sun and colleagues report that, during 10 years of follow-up, the cumulative incidence of first stroke was 12.5% and for myocardial infarction (MI) the rate was 8.3%.
One of the biggest independent risk factors for stroke was hypertension, which conferred a significant 1.39-fold increased risk. Current smoking and diabetes were associated with significant 1.16- and 1.15-fold increased risks respectively, while having at least one uncontrolled CV risk factor at HNSCC diagnosis was associated with a significant 1.09-fold higher stroke risk relative to having no uncontrolled risk factors.
Receipt of radiotherapy and chemotherapy as part of HNSCC treatment were associated with a 1.16-fold and 1.18-fold increased risks for stroke, respectively.
The researchers observed similar results for MI, with hypertension and diabetes conferring 1.29- and 1.27-fold increased risks, respectively. Current smoking and receipt of radiotherapy or chemotherapy were not independently associated with MI risk, but having one or more uncontrolled CV risk factor was associated with a significant 1.19-fold increased risk. Furthermore, having larynx, oral cavity, and hypopharynx cancers as the primary site were each associated with a higher risk for MI compared with oropharynx cancer.
Finally, the investigators showed that incident stroke and MI impacted mortality. Specifically, individuals with incident stroke had a significant 47% higher risk for death than those without stroke, while the risk was 71% higher for people with versus without incident MI.
Sun and co-workers said that the elevated CV risk among patients with HNSCC “is hypothesized to be secondary to (1) shared risk factors that predispose to a patient to cancer and CV [disease] (including smoking, alcohol use, and older age) and (2) exposure to potentially cardiotoxic therapies as part of cancer treatment.”
The researchers believe their findings “have several potentially important clinically actionable implications,” including increased CV risk factor monitoring and optimization of risk factors among patients with newly diagnosed HNSCC, particularly those in subpopulations at high CV risk.
