Cardiac events reduced by half with prostate cancer drug
A recent paper published in European Urology, the official journal of the European Association of Urology, indicates that the gonadotropin releasing hormone (GnRH) antagonist degarelix (Firmagon), may halve the relative risk of cardiovascular (CV) events and death in men with pre-existing CV disease (CVD) compared to treatment with commonly prescribed luteinising hormone-releasing hormone (LHRH) agonists.
The report is based on a pooled analysis of 2,328 men with prostate cancer from six prospective, randomised trials.
Study co-author Jan Nilsson MD, Department of Clinical Sciences, Lund University, Sweden, said, “One recent study suggests that cardiovascular disease is among the most common causes of early mortality in men with advanced prostate cancer, not the cancer itself. As a cardiologist I want urologists to be aware of this and to consider CV risk when selecting treatment options for their patients and analyses such as this are a positive step towards helping them to do just that.”
The paper entitled “Cardiovascular Morbidity Associated with Gonadotropin Releasing Hormone Agonists and an Antagonist,” reported that for men with pre-existing CVD at baseline there were ‘significantly fewer cardiac events or deaths’ experienced by patients receiving degarelix (6.5%) compared with patients receiving LHRH agonists (14.7%). A Cox proportional hazard model showed a 56% lower risk of a cardiac event or death during the initial year of treatment for men receiving degarelix compared with men receiving LHRH agonists (CI 0.26-0.74, p=0.002). The absolute risk reduction during the first year was 8.2% which yields a number needed to treat of 12.
Among the men who had no pre-existing cardiovascular disease at baseline there was no difference in the incidence of either death from any cause or the incidence of cardiac events. Moderate alcohol consumption and a low baseline serum testosterone level were the only other predictors of a lower risk of a cardiac event or death.
In the six prospective randomised trials included in the analysis, cancer patients were randomised to receive androgen deprivation therapy (ADT) in the form of GnRH antagonist degarelix (1,491) or an existing LHRH agonist (458 received goserelin and 379 received leuprolide). Most patients (72%) received treatment for one year, while the remaining patients were treated for three to seven months. Both treatment groups were well balanced for baseline characteristics eg. statin medication, elevated blood pressure, diabetes, cholesterol and history of CV disease. The CV event analysis was based on death from any cause or a serious CV event defined as arterial, embolic /thrombotic; haemorrhagic/ischaemic cerebrovascular; myocardial infarction or other ischaemic heart disease.
Laurence Klotz MD, Division of Urology, University of Toronto, Ontario, Canada said: “Androgen deprivation therapies play an important role in the treatment of men with prostate cancer. As these therapies become more widely used and for longer periods of time, we are understanding more about what needs to be done to help patients beyond management of the cancer itself. I believe this analysis provides insights which have the potential to help physicians better manage the cardiovascular health of their androgen deprivation therapy patients—particularly those with pre-existing cardiovascular disease”.
TAVI as a paradigm of a multidisciplinary approach to geriatric medicine
Transcatheter Aortic Valve Implantation (TAVI), a rapidly evolving, minimally-invasive heart valve replacement procedure for elderly patients with severe symptomatic aortic stenosis, was one of the focuses of the 9th meeting of the European Union Geriatric Medicine Society (EUGMS), in Venice, Italy.
In a session entitled: “TAVI as a paradigm of a multidisciplinary approach to the geriatric patient,” Professor Jean-Pierre Michel, President, EUGMS, said: “Patients may demonstrate non-specific, atypical clinical presentations and multiple comorbidities, calling for co-operation with other specialists, including general practitioners, nurses and paramedical disciplines. With regard to TAVI, in addition to integration within Heart Teams, geriatricians should be involved in the early stages of patient management and also during rehabilitation.”
The EUGMS keynote speech was delivered at the opening ceremony by Professor Alain Cribier, who developed and performed with his team the first TAVI in 2002. He said: “TAVI is a prime example of a new procedure that brings quality of life improvements specifically to elderly patients. Since the first case over ten years ago, and despite initial resistance, over 80,000 patients have now benefitted from TAVI.”
Professor Cribier noted that at 85 years of age, around 8% of today’s population can expect to have aortic stenosis, a condition characterised by the calcification and stiffening of the aortic valve. “Given the increasing proportion of elderly individuals in the population, aortic stenosis will become a significant burden. Considering that disease-modifying pharmaceutical therapies are not available, and that many patients are inoperable or at high risk of open heart surgery, TAVI has been a very significant development.”
To better understand the role of geriatricians in the management of aortic stenosis, EUGMS members were invited to participate in an online survey. “The survey demonstrated the considerable potential for increased involvement of geriatricians in the management of aortic stenosis,” said Professor Andrea Ungar, Chairman of the EUGMS Working Group on TAVI. “Decision-making with TAVI is led by multi-disciplinary teams. The input of geriatricians, with particular regard to frailty, nutrition and age-related disability, is invaluable.”
He added that valvular aortic stenosis in adults is progressive and life threatening. One third of the patients with aortic stenosis are not referred from cardiologists for replacement. The PARTNER Study (average age 83 years) showed a 20% reduction in death from any cause at one year for those patients treated with TAVI. Until now this research type was only performed by cardiologists.
The survey found that on average, respondents spend more than 50% of their working time on acute care and the rest on long-term care and rehabilitation. 31% of respondents indicated that they managed patients with aortic stenosis on a frequent basis and almost a quarter of patients with aortic stenosis seen were regarded as severe cases.
The survey also found that only a minority of respondents (17%) who referred patients for TAVI in the past two years are members of a multidisciplinary heart team for the management of patients who are considered for TAVI. It also discovered that geriatrician involvement is very low.
Professor Stefania Maggi, President of the EUGMS Congress added: “By 2050, more than 240 million Europeans will be aged 60 or over. Of this group, almost 68 million will be aged 80 or more, greater than the population of most European countries, including Italy, France and the United Kingdom. This significant challenge to Europe’s healthcare system will require innovative solutions and therapies.”
A registry, carried out in collaboration with the EUGMS and Edwards Lifesciences, aim to expand upon existing data sets with a special focus on elderly patients to establish the predictive value of the Comprehensive Geriatric Assessment for functional improvement and mortality in TAVI patients.
Ocular blood flow and atherosclerosis linked in diabetes patients
In a study to evaluate the relationship between ocular blood flow, diabetic retinopathy and coronary artery disease in patients with diabetes, researchers found that ocular hemodynamic impairments within the eye are associated with atherogenic changes of coronary arteries.
Krasnicki and colleagues reported in the British Journal of Ophthalmology that they divided 56 participants into the following groups: 13 patients with diabetes and without coronary artery disease (CAD); 29 patients with diabetes and CAD; 20 patients without retinopathy; and nine patients with retinopathy.
The participants each provided their medical history and underwent an ophthalmic evaluation, including visual acuity, intraocular pressure, slit-lamp examination and direct and indirect ophthalmoscopy. Patients diagnosed with CAD were done so after a coronary angiogram. Researchers also used color Doppler imaging to assess end-diastolic and peak systolic blood velocities and resistivity indexes in the ophthalmic, central retinal and posterior ciliary arteries, as detailed in the study.
Results showed that patients with type 2 diabetes experienced blood flow disruptions within their ocular blood vessels due to the hardening of their coronary arteries, according to the study. They also suggested that diabetic retinopathy was associated with blood flow impairment within the central retinal artery in patients with both diabetes and CAD, but that disturbed blood flow in the ophthalmic and posterior ciliary arteries was not related to diabetic retinopathy.
“We propose that the changes in central retinal artery blood flow parameters in patients with type 2 diabetes can be explained by microvascular and macrovascular changes,” the authors concluded. “There are few contradictory papers that address the issue of ocular hemodynamics in diabetic patients with and without CAD. The strengths of our study include standardised assessment of diabetic retinopathy and evaluation of atherogenic changes in the coronary arteries based on coronary angiogram. A better understanding of ocular hemodynamics may provide insight into the pathogenesis of ischaemic, potentially devastating, ocular changes in patients with diabetes and CAD.”
Cancer rate higher in men than women
Global cancer death rates are more than 50% higher in men than women, according to figures published recently by Cancer Research UK.
The statistics reveal that more than 4.6 million men die from the disease every year—equivalent to 126 men in every 100,000, compared to around 3.5 million women—82 women per 100,000.
The total number of global cancer deaths stands at more than eight million each year. The four biggest killers are lung, liver, stomach and bowel cancers, which together are responsible for nearly half of all cancer deaths globally.
And, across the globe, there is wide variation in men’s death rates, which are highest in Central and Eastern Europe. East Africa has the highest death rates for women and is one of the few areas where rates for women are higher than for men. But the accuracy of the data also varies substantially— countries in the developed world with higher rates of cancer are more likely to have better data sources and therefore more accurate cancer data.
The figures also show that, every year, more than 14 million people around the world are diagnosed with cancer, with men 24% more likely to be diagnosed with the disease.
The figures, compiled by the International Agency for Research on Cancer, are announced as Cancer Research UK unveils a new interactive map, which compares cancer statistics from around the world. The map shows the variation in incidence, mortality and, importantly, the reliability of the data in each country and region. You can see the map by visiting: http://www.cancerresearchuk.org/cancer-info/cancerstats/world/
Nick Ormiston-Smith, head of statistics at Cancer Research UK, said: “The contrast in cancer death rates between the sexes may be down to more men being diagnosed with types of cancers that are harder to treat, such as cancers of the bladder, liver, lung and oesophagus. Cancer is estimated to account for around 16% of all deaths worldwide. Age is the biggest risk factor for most cancers and, as global life-expectancy increases, we’ll see more people being diagnosed with the disease.”