A discussion on the management of cardiovascular risk for patients with prostate cancer receiving ADT therapy.
PUBLISHED May 10, 2019
Susan F. Slovin, M.D., Ph.D.: Andy, we talked about cardiovascular risk factors quite a bit, and one of the issues is how much gravity or seriousness should we be attributing to a lot of these since there are different levels of triglycerides, different levels of cholesterol, and of course, there are new guidelines out. I think what we are very concerned about is what we call the major cardiovascular events. And that includes myocardial infarction, stroke, the need for either angioplasty or some sort of intervention to immediately intercede.
There have been some data out there suggesting that the type of treatment that we use to suppress testosterone may in fact contribute toward a cardiovascular event. And there have been data throughout the years, a lot of studies suggesting that use of a GnRH [gonadotropin-releasing hormone] antagonist such as leuprolide [Note: leuprolide is a GnRH agonist], could increase cardiovascular risk. Now there have been a number of studies, one by Peter Albertsen M.D. among others, to suggest that using a GnRH antagonist that you mentioned earlier, degarelix, which immediately drops the level of testosterone and you don’t get these little micro surges in FSH [follicle-stimulating hormone] and LH [luteinizing hormone], may have fewer cardiovascular risks. In fact, there’s actually a 900-patient phase 3 trial that is comparing leuprolide and degarelix in terms of major cardiovascular risk. And right now I think they’ve accrued about 250 patients. So this is an area of interest that is being taken very seriously.
But I get a sense sometimes that we as medical oncologists, and even our internists, may not take with the same level of seriousness, “Well, you have a little bit of hypertension, a little bit of cholesterol, don’t worry about it.” So how does a patient educate himself if his doctor’s not being proactive or if you don’t think you doctor is being proactive? And again, you were very fortunate to have somebody that good and aware of things. But how do you educate yourself? I mean, “Oh I had a little hypertension, a little diabetes; oh, I go to my doctor once a year, my stress test is negative.” But these things creep up on you.
So how does a patient become proactive? Not everybody has the same level in terms of educational background or level of sophistication. Very often they rely on medical oncology to be the end-all and be-all of their medical care, but it’s hard and we don’t do that.
Andy Rochester: Yes, because you can’t really run the other departments.
Susan F. Slovin, M.D., Ph.D.: Exactly right. Do you think just telling people to change their lifestyle? Not everybody has the same level of initiative or proactivity that you had and continue to have. But certainly there’s aspirin, there are other holistic approaches that are based on preclinical work but not necessarily in clinical benefit. So how do you tell people, “Don’t go with the fad?”
Andy Rochester: Yes, because think of all the people who put themselves on low-dose aspirin just because they read so many articles it was a great idea. And now to see the articles coming back out again, albeit mainly from the lay press but also being fed by the majors, that some of these are just really not a good idea. Where do you find the truth?
Susan F. Slovin, M.D., Ph.D.: Do you find that your friends, for example, are particularly forthcoming with their doctors? Because I often have patients who come in, they’ll mention they have a little bit of hypertension. Of course then we take their blood pressure and they’re 160/90. “Oh, I just have a little bit of issues,” and you find out, as time comes, not everybody is very forthcoming for the simple reason patients seem to think that we withhold treatment, or will not make the same recommendations once we learn that there are other medical comorbidities that are ongoing.
Andy Rochester: It’s a shame because actually if they would be more forthright with it, and this is the thing I was saying earlier, which is the fact that you have to develop the good rapport with your physician team, and you’ve really got to come clean. And if somebody comes back with a finding, instead of doing the normal human thing, which is to try and minimize, “I’m just a little diabetic, I’m just a little bit hypertensive,” you’ve got to turn things around and say, “I’m hypertensive, doctor, what do I need to do for that?” And that’s what I did. I basically said, “I’m obese, I’m hypertensive, I’ve got cancer, I’ve got all these things going on.” So I decided, OK, turn it around.
Susan F. Slovin, M.D., Ph.D.: Had you ever smoked?
Andy Rochester: No.
Susan F. Slovin, M.D., Ph.D.: So in addition to recommending to a lot of patients smoking cessation, improving nutrition, exercise, alcohol in moderation, what about stress reduction? That seems to be a major question from our patients.
Andy Rochester: I did the big three. Basically the first one was exercise, we already talked about that. We talked about diet to some degree. I wanted to touch on, pretty much I eliminated meat. I eliminated the dairy for the most part. I don’t really have ice cream. My cardiologist said, I had ice cream once the first year, and he said, “You need to live it up more.” So I had ice cream three times the next year.
I try to be careful. Diet, so everything says you should eat fish. So I eat fish that are fatty fish, fish with omegas in them, and I kid because I say apparently chickens can swim, because I will fall back to chicken or tuna. But I don’t do red meat and those kinds of things. So most of the diet seems straightforward. I said no more alcohol. And so, you’re going to do it, like I said before, or you aren’t. And at the same time I was thinking about what my mental outlook was, to your point more directly.
I found that I had a very energetic type of job situation before my diagnosis, and I’ve shifted my work around. I was really afraid of my mind actually ever getting it to calm itself, to actually settle down and calm itself. So I started to do meditation just to calm my mind. And then, this may sound a little bit odd, but I actually separated, in my mind, my day-to-day living so that I pretty much live in the day and I set the cancer side of me, my body, I set it aside. So I feed my body, I exercise it, I take good care of it. It’s got cancer. If it dies of cancer, oh well, that is what it is. We’re doing everything we can, but I am not going to ruin my day because of that problem.
Susan F. Slovin, M.D., Ph.D.: We’ve touched upon the need, and the recommendation I guess, for multidisciplinary approach. You’ve already indicated how successful that’s been for your care. What are your thoughts about how patients who go on androgen deprivation therapy [ADT], should receive their care? Should all of the patients who carry a diagnosis of prostate cancer, number one, should they go directly; if they’re going to go on androgen deprivation therapy, should they see a cardiologist first as a baseline? Is it enough for them to see their internist? Because, again, not everybody is really clued in to how androgen deprivation therapy affects the cardiovascular system. Your experience has been very fortunate for you, but not everybody has that kind of experience.
Andy Rochester: Right.
Susan F. Slovin, M.D., Ph.D.: What would you recommend to people now? And actually to the doctors because we are learning from the patients as well.
Andy Rochester: I was extraordinarily lucky in this situation because it got picked up with silent heart disease, and the cardiologist was frank with me. He said that you’re likely to have an event, and you basically will have one, which is what killed my dad. And I thought, OK. Then after I followed all of the solutions that we talked about earlier, after about six months of that, I would actually shift, because of stability in the heart and so forth, to unlikely to have an event.
So I’m a big proponent because here I had, other than hypertension, which is a big risk factor all by itself, a family history of it. And so many people are either prediabetic or they have heart disease in the family and then you add this overlay of ADT to it, absolutely. I think that cardiologists, like you said, should get a baseline, and then the testing may pick up something that’s never been picked up in a routine EKG [electrocardiogram]. In my case it didn’t elicit itself until it was a stress test. And so if someone is going to go into the involvement of ADT therapy, then I think there would be a concomitant justification perhaps to have it; not everybody gets a stress test.