Risk of Cardiovascular Events Among Patients With Head and Neck Cancer

Abstract

ImportanceCardiovascular (CV) disease is a substantial cause of morbidity and mortality in cancer due to shared risk factors and exposure to potentially cardiotoxic cancer therapy. However, our understanding of CV risk in patients with head and neck squamous cell carcinoma (HNSCC) is limited.ObjectiveTo define CV risk profiles, incident stroke, myocardial infarction (MI), and mortality in patients with HNSCC.Design, Setting, ParticipantsThis retrospective, population-based cohort study included 35 897 US veterans with newly diagnosed HNSCC from January 1, 2000, to December 31, 2020. Data were analyzed from May 2022 to January 2023.ExposuresDemographic, cancer-specific, and treatment characteristicsMain OutcomesPrevalence of CV risk factors, medication use, and control at HNSCC diagnosis; cumulative incidence of stroke and MI; and all-cause death.ResultsOf 35 857 US veterans with HNSCC (median [IQR] age, 63 [58-69] years; 176 [0.5%] American Indian or Alaska Native, 57 [0.2%] Asian, 5321 [16.6%] Black, 207 [0.6%] Native Hawaiian or Other Pacific Islander, and 26 277 [82.0%] White individuals), there were high rates of former or current smoking (16 341 [83%]), hypertension (24 023 [67%]), diabetes (7988 [22%]), and hyperlipidemia (18 421 [51%]). Although most patients were taking risk-lowering medications, 15 941 (47%) had at least 1 uncontrolled CV risk factor. Black race was associated with increased risk of having uncontrolled CV risk factor(s) (relative risk, 1.06; 95% CI, 1.03-1.09), and patients with larynx cancer had higher rates of prevalent and uncontrolled risk factors compared with other cancer subsites. Considering death as a competing risk, the 10-year cumulative incidence of stroke and MI was 12.5% and 8.3%, respectively. In cause-specific hazards models, hypertension, diabetes, carotid artery stenosis, coronary artery disease, and presence of uncontrolled CV risk factor(s) were significantly associated with stroke and MI. In extended Cox models, incident stroke and MI were associated with a 47% (95% CI, 41%-54%) and 71% (95% CI, 63%-81%) increased risk of all-cause death, respectively.ConclusionThe results of this cohort study suggest that in HNSCC, the burden of suboptimally controlled CV risk factors and incident risk of stroke and MI are substantial. Modifiable CV risk factors are associated with risk of adverse CV events, and these events are associated with a higher risk of death. These findings identify populations at risk and potentially underscore the importance of modifiable CV risk factor control and motivate strategies to reduce CV risk in HNSCC survivorship care.

Stroke Risk in Survivors of Head and Neck Cancer

“…Hypertension and diabetes have been shown to be associated with stroke in HNC . More importantly, a study of US veterans found that 47% of patients with HNC had uncontrolled cardiovascular risk factors at diagnosis, which were shown to be associated with incident stroke . Survivorship programs should focus on active screening and management of modifiable cerebrocardiovascular risk factors.…”

“… 30 More importantly, a study of US veterans found that 47% of patients with HNC had uncontrolled cardiovascular risk factors at diagnosis, which were shown to be associated with incident stroke. 31 Survivorship programs should focus on active screening and management of modifiable cerebrocardiovascular risk factors. However, there is a paucity of evidence on specific stroke prevention measures in HNC.…”

Vascular events in patients with head and neck cancer: A systematic review and meta‐analysis

“…9 The rate of MI has been most recently reported in 2023 as 8.3% in a population-based cohort of patients with HNC, though the study acknowledges the high level of confounding due to risk factors in this population. 170 T A B L E 6 Meta-proportions of vascular event incidence in HNC patients undergoing chemotherapy as primary treatment modality. While the previously mentioned database study reported an increase in hazard ratio for MI, our study found an incidence that is lower than the reported nation-wide rate of 3% for the United States between 2013 and 2016.…”

Statins in Cancer Prevention and Therapy

“…Successfully treated HNC patients remain at high risk of both secondary cancers and non-cancer causes of death [180]. Cardiovascular disease and stroke appear to be particularly increased in treated HNC patients [181]. Although the advanced age and history of smoking typical of HNC patients may be most responsible, there is a specific risk of stroke that has been linked to vascular injury during radiotherapy [182].…”