Cardiovascular disease risk assessment and multidisciplinary care in prostate cancer treatment with ADT: recommendations from the APMA PCCV expert network

Abstract

Purpose: Androgen deprivation therapy (ADT) is the mainstay approach for prostate cancer (PCa) management. However, the most commonly used ADT modality, gonadotropin-releasing hormone (GnRH) agonists, has been associated with an increased risk of cardiovascular disease (CVD).

Methods: The PCa Cardiovascular (PCCV) Expert Network, consisting of multinational urologists, cardiologists and oncologists with expertise in managing PCa, convened to discuss challenges to routine cardiovascular risk assessment in PCa management, as well as how to mitigate such risks in the current treatment landscape.

Results: The experts identified several barriers, including lack of awareness, time constraints, challenges in implementing risk assessment tools and difficulties in establishing multidisciplinary teams that include cardiologists. The experts subsequently provided practical recommendations to improve cardio-oncology care for patients with PCa receiving ADT, such as simplifying cardiovascular risk assessment, individualising treatment based on CVD risk categories, establishing multidisciplinary teams and referral networks and fostering active patient engagement. A streamlined cardiovascular risk-stratification tool and a referral/management guide were developed for seamless integration into urologists' practices and presented herein. The PCCV Expert Network agreed that currently available evidence indicates that GnRH antagonists are associated with a lower risk of CVD than that of GnRH agonists and that GnRH antagonists are preferred for patients with PCa and a high CVD risk.

Conclusion: In summary, this article provides insights and guidance to improve management for patients with PCa undergoing ADT.

Keywords: Androgen deprivation therapy; Cardiovascular disease; Cardiovascular toxicity; Interdisciplinary; Prostate cancer; Risk management.

Fig. 1

Checklist for CVD risk assessment and stratification. Adapted from Davey P and Alexandrou K. Int J Clin Pract; 2022 [3]. A minimum of one check-marked condition is needed to select “Yes” in a subsequent text box. *A patient’s risk level may transition from “Low Risk” to “Intermediate Risk” or “High Risk” after 2 or 3 years of hormonal plus NHA treatment. CVD, cardiovascular disease; NHA, novel hormonal agent; PCa, prostate cancer

Fig. 2

Management steps for minimising cumulative CVD risk at ADT initiation. *Referral to cardiologists is recommended but is subject to each country’s healthcare system and resources. ADT, androgen deprivation therapy; CV, cardiovascular; CVD, cardiovascular disease; GnRH, gonadotrophin-releasing hormone; PCa, prostate cancer

Fig. 3

Optimal workflow for the multidisciplinary management of PCa and CVD. Dotted arrows indicate the necessity of interdisciplinary co-management of patients, highlighting the importance of ongoing communication between healthcare disciplines throughout the management of PCa. There is a need for interdisciplinary communication for the duration of management of PCa, especially in cases where high CVD risk is observed at diagnosis. ^aInclude treatment of diabetes or hyperlipidaemia, smoking cessation, regular exercise, weight reduction to BMI < 25 kg/m². ^bInclude heart attack in the past 1 year, ongoing chest pain or discomfort. ADT, androgen deprivation therapy; BMI, body mass index; CV, cardiovascular; CVD, cardiovascular disease; MDT, multidisciplinary team; PCa, prostate cancer.