Cardiovascular co-morbidity in cancer patients: the role of psychological distress

Abstract

Due to aging of the population and cardiotoxic cancer treatment, there is an increasing group of patients with cancer and co-morbid cardiovascular disease (CVD). In order to find a balance between the risk of undertreating the malignancy on the one hand and inducing CVD on the other hand, CVD risk stratification at the time of cancer diagnosis and knowledge on the pathway for developing incident CVD in cancer patients is vital. In this paper, we propose an adapted multiple-hit hypothesis for developing CVD in cancer patients describing that patients with cancer are exposed to a series of sequential or concurrent events that together make them more vulnerable to reduced cardiovascular reserves, development of incident CVD and ultimately death. We highlight the possible impact of psychological distress secondary to a cancer diagnosis and/or treatment, which in turn may increase the risk of incident CVD in patients diagnosed with cancer. Furthermore, we discuss potential behavioral and pathophysiological mechanisms underlying the link between psychological distress and the pathophysiology of incident CVD. In addition, key unanswered questions for future research are posed. In the future, researching the adapted multiple-hit hypothesis for developing CVD among cancer patients will hopefully advance the care of cancer patients by finding some of the missing pieces of the puzzle. To do so, we need to focus on minimizing cardiovascular risk and promoting cardiovascular health in cancer patients by addressing the knowledge gaps formulated in this paper.Keywords: Cancer, Survivors, Cardiovascular, Psychological distress, Mechanisms Cardiovascular co-morbidity in cancer patientsDue to aging of the population, there is an increasing number of patients with cancer and co-morbid cardiovascular disease (CVD). Additionally, cancer patients may develop incident CVD as a result of the cardiotoxicity of cancer treatment. Fortunately, there has been increasing awareness of co-morbid CVD in cancer patients. In 2009, the International CardiOncology Society (ICOS) was established [1]. ICOS advocates a multi-disciplinary effort to combat CVD in cancer patients by both training oncologists and cardiologists and conducting multidisciplinary research. In 2014, during the international colloquium on cardio-oncology, ICOS stressed the importance of finding a balance between the risk of undertreating the malignancy on the one hand and inducing CVD by overtreating on the other hand [2]. In order to accomplish this goal, they emphasize the importance of CVD risk stratification at the time of cancer diagnosis. Recommendations based on consensus have also been published to target the vulnerable cancer patient population, emphasizing the importance of a thorough cardiac evaluation, including the assessment of risk factors, prior to formulating a cancer treatment plan [3].Adapted multiple-hit hypothesis: the impact of psychological distress Important in CVD risk stratification is knowledge of the pathway for developing CVD in cancer patie...

Incidence of cardiovascular disease up to 13 year after cancer diagnosis: A matched cohort study among 32 757 cancer survivors

“…Third, research within the field of cardiology has suggested that individuals who experience high levels of stress, or experience symptoms of depression or anxiety have an increased risk of incident CVD . It is well known that both a diagnosis of cancer and its associated treatment may increase stress, anxiety, and depression, which could potentially exacerbate the risk of incident CVD in cancer survivors …”

“…28 It is well known that both a diagnosis of cancer and its associated treatment may increase stress, anxiety, and depression, 26,29,30 which could potentially exacerbate the risk of incident CVD in cancer survivors. 6,31 By correcting for the presence of traditional cardiovascular risk factors prior to cancer diagnosis, and by using a strict definition of CVD, we may be missing the precursors of CVD and thus underestimate the risk of CVD in cancer survivors. Our finding that the increased CVD risk among prostate cancer survivors compared to matched cancer-free controls was limited to those who did not have any traditional cardiovascular risk factors prior to their cancer diagnosis is interesting.…”

“…Cancer survivors can develop a range of CVDs, such as arrhythmias, myopericarditis, myocardial infarction, cardiomyopathy, cardiac failure, valvular disease, and congestive heart failure after cancer treatment . Besides similarities in risk factors for both cancer and CVD, the cardiotoxic effect of certain cancer therapies poses a risk to cancer survivors . Several pathophysiological mechanisms such as oxidative stress as a result of anthracycline generated free radicals and increased inflammation have been suggested to be involved in the pathogenesis of CVD in cancer survivors …”

“…4,5 Besides similarities in risk factors for both cancer and CVD, the cardiotoxic effect of certain cancer therapies poses a risk to cancer survivors. 6 Several pathophysiological mechanisms such as oxidative stress as a result of anthracycline generated free radicals and increased inflammation have been suggested to be involved in the pathogenesis of CVD in cancer survivors. 4,7 Current studies on incident CVD in cancer survivors mostly include just one malignancy, hence large population-based studies focusing on patients with various cancer types are scarce.…”

The risk of developing cardiovascular disease is increased for patients with prostate cancer who are pharmaceutically treated for depression

“…Prevalence rates for anxiety and depression range from 15% to 27%, hence one in every five prostate cancer survivors are afflicted [14,15]. Consequently, prostate cancer survivors may have an increased risk of incident CVD if only by these elevated levels of psychological distress after cancer diagnosis [16]. Indeed, a study by our group amongst breast cancer survivors showed that pharmaceutically treated anxiety prior to cancer diagnosis increases the risk of incident CVD, while controlling for depression, traditional cardiovascular risk factors, and clinical factors [17].…”