Cardiovascular Risks in Long-Term Cancer Survivors

“Cardiovascular Risk in Long-Term Survivors of Breast, Prostate, Colon, and Rectal Cancer”  by Sarah J. Westvold, MPH, Jessica B. Long, MPH, Jane Fan, MPH, Madhav Kc, MPH, PhD, Terry Hyslop, PhD, et al.

Clinical Summary from Jay K. Harness, MD, FACS

This large SEER-Medicare cohort study evaluated 95,100 long-term (≥5-year) survivors of breast, prostate, colon, and rectal cancer aged ≥66 to characterize cardiovascular disease (CVD) risk between 5–15 years after cancer diagnosis. The study provides timely insights for oncology, primary care, and cardiology teams caring for older survivors who increasingly die from non-cancer comorbidities, particularly CVD.

Major Clinical Outcomes

Across cancers, 23.2% of long-term survivors experienced late CVD—defined as myocardial infarction, stroke, congestive heart failure, cardiomyopathy, or CVD-related death—during the follow-up window. Notably, CVD mortality exceeded cancer-specific mortality in breast, prostate, and colon cancers, emphasizing that cardiovascular health becomes a dominant determinant of long-term outcomes.

Strongest predictors of CVD:

The most powerful drivers of late CVD were non-cancer-related factors, especially:

• Advanced age: Risk rose markedly after age 80.
• Preexisting CVD: The single strongest predictor. A prior acute event conferred up to 32% shorter CVD-free survival in colon cancer survivors.
• Comorbidities: Diabetes, hypertension, peripheral vascular disease, and hyperlipidemia were consistently associated with a shorter event-free survival period.

These findings highlight that traditional cardiovascular risk factors, not cancer-specific features—dominate late-phase survivorship risk.

Cancer-Related Predictors

Surprisingly, most cancer-specific variables, including chemotherapy, radiation, cancer stage, or endocrine therapy, were not independently associated with late CVD once survivors reached the 5-year mark. This suggests that:

• Treatment-related cardiotoxicity is more likely to manifest within the first 1–2 years, and
• Survivors who remain event-free to year 5 may represent a cardiovascular resilient subgroup.

Exceptions included:

• Stage III breast cancer, associated with a modest (3–6%) shorter CVD-free interval.
• Prostate radiation + androgen deprivation therapy (ADT), which contributed to a small but significant increase in late CVD risk.

Overall, however, cancer-agnostic models may adequately predict cardiovascular outcomes in older survivors.

Risk Stratification Model

The authors developed a clinically intuitive risk-scoring tool incorporating age, comorbidities, and prior CVD. High-risk survivors had three- to four-fold higher CVD incidence than low-risk survivors. In all cancer types, the high-risk strata experienced more CVD events than non-CVD deaths, underscoring the clinical relevance of systematic cardiovascular risk assessment.

Social determinants also mattered: survivors living in higher-poverty neighborhoods and those unmarried were more frequently positioned in the high-risk tier.

Key Take-Away Messages for Cancer Healthcare Providers

1. CVD is a leading threat to long-term survival in older cancer survivors, often surpassing cancer recurrence as the primary cause of death.
2. Routine CVD risk assessment should begin at the 5-year mark, using a cancer-agnostic approach focused on age, comorbidities, prior CVD events, and social determinants.
3. Coordination between oncology, primary care, and cardiology is essential to deliver appropriate preventive care (blood pressure control, diabetes management, lipid lowering, lifestyle counseling).
4. Treatment-related cardiotoxicity remains important early on, but traditional cardiovascular risk factors overwhelmingly drive late CVD events.
5. Survivors receiving prostate radiation + ADT or those with stage III breast cancer may benefit from closer cardiac surveillance, although absolute effect sizes are small relative to aging and comorbidities.

Key Messages for Cancer Patients

• Heart health becomes crucial after cancer treatment. After five years, the biggest health risks often shift from cancer recurrence to heart disease.
• Managing blood pressure, diabetes, cholesterol, weight, and physical activity is essential for long-term survival.
• A history of heart problems increases future risk. Survivors should maintain regular check-ups with primary care and cardiology.
• Long-term survivors should view cardiovascular prevention (exercise, nutrition, smoking cessation, medication adherence) as a core part of cancer survivorship care.
• Patients should feel empowered to ask:
  “What is my heart disease risk, and how can I reduce it?”

Reference: Journal of the National Cancer Institute, 2025https://doi.org/10.1093/djaf243