乳腺癌康复者未坚持心血管用药的风险

　　心血管疾病是早期乳腺癌患者的主要死亡原因。不过，乳腺癌康复者坚持心血管疾病风险因素（高血压、高血脂、高血糖）用药的比例较低，未坚持心血管疾病风险因素用药的现象十分普遍。

　　2020年1月8日，美国癌症学会《癌症》在线发表纽约哥伦比亚大学医学中心、西雅图弗雷德哈钦森癌症研究中心的研究报告，探讨了乳腺癌康复者未坚持心血管疾病风险因素用药与心血管事件之间的关系。

　　该研究将美国国家癌症研究所（NCI）监测流行病学最终结果（SEER）数据库与联邦医疗保险（Medicare）处方药数据库进行关联，对2008～2013年被诊断为I～III期乳腺癌之前服用至少一种心血管疾病风险因素药物的1万5576例年龄≥65岁患者进行分析。通过逻辑回归模型，确定未坚持心血管疾病风险因素用药相关因素。通过多因素比例风险回归模型，计算乳腺癌治疗后新发心脏事件与未坚持心血管疾病风险因素用药之间的关系。

　　结果，4797例患者（30.8%）乳腺癌首次治疗期后未坚持服用至少一种心血管疾病风险因素药物。

　　未坚持心血管疾病风险因素用药的显著相关因素包括：黑人种族、合并症指数较高、癌症分期较高、激素受体阴性、接受化疗。

　　乳腺癌治疗后未坚持与坚持心血管疾病风险因素用药的患者相比，随后心脏事件风险高1.15倍（95%置信区间：1.00～1.33，P=0.06）。未坚持用药越多，随后心脏事件风险越高（P<0.01）。

　　与坚持心血管疾病风险因素用药的患者相比：

• 未坚持高血压用药：随后心脏事件风险高1.33倍（95%置信区间：1.18～1.51，P<0.0001）

• 未坚持高血脂用药：随后心脏事件风险高1.21倍（95%置信区间：1.05～1.40，P=0.009）

• 未坚持高血糖用药：随后心脏事件风险高1.31倍（95%置信区间：1.10～1.56，P=0.003）

　　因此，该研究结果表明，乳腺癌治疗后未坚持与坚持心血管疾病风险因素用药的老年患者相比，心脏事件风险较高。为了改善乳腺癌诊断后结局并减少发病，还需要重视乳腺癌以外的疾病。

Cancer. 2020 Jan 8. [Epub ahead of print]

Association between nonadherence to cardiovascular risk factor medications after breast cancer diagnosis and incidence of cardiac events.

Hershman DL, Accordino MK, Shen S, Buono D, Crew KD, Kalinsky K, Trivedi MS, Hur C, Hu J, Unger JM, Wright JD.

Columbia University Medical Center, New York, New York; Fred Hutchinson Cancer Research Center, Seattle, Washington.

Nonadherence to cardiovascular disease risk factor medications after treatment of breast cancer is common. It is concerning that in the current study, nonadherence appears to result in an increased risk of a cardiac event. Improving outcomes and reducing morbidity after a diagnosis of breast cancer require attention to nonbreast cancer conditions.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among patients with early-stage breast cancer (BC), but adherence to cardiovascular disease risk factor (CVD-RF) medications is reported to be poor in BC survivors. The objective of the current study was to determine the association between nonadherence to CVD-RF medications and cardiovascular events in BC survivors.

METHODS: The authors included patients with stages I to III BC from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database who had Medicare part D coverage and who were taking at least 1 CVD-RF medication prior to their BC diagnosis (2008-2013). Logistic regression was performed to define factors associated with nonadherence. Cox regression was used to calculate the association between nonadherence and new cardiac events after treatment.

RESULTS: Among 15,576 patients included in the current analysis, 4797 (30.8%) were nonadherent to at least 1 category after the initial BC treatment period. Black race, greater comorbidity burden, more advanced cancer stage, hormone receptor-negative status, and receipt of chemotherapy were found to be associated with nonadherence. Nonadherence after treatment demonstrated a trend toward an increased risk of a subsequent cardiac event (hazard ratio [HR], 1.15; 95% CI 1.00-1.33 [P = .06]). This effect size increased with nonadherence to a greater number of medications (P < .01). There was an increased risk of experiencing a cardiac event noted with becoming nonadherent to hypertension medications (HR, 1.33; 95% CI, 1.18-1.51 [P < .0001]), hyperlipidemia medications (HR, 1.21; 95% CI, 1.05-1.40 [P = .009]), and diabetes medications (HR, 1.31; 95% CI, 1.10-1.56 [P = .003]).

CONCLUSIONS: Nonadherence to CVD-RF medications after treatment of BC is associated with an increased risk of a cardiac event. Improving outcomes and reducing morbidity after a diagnosis of BC requires attention to non-BC conditions.

KEYWORDS: adherence; breast cancer; cardiovascular outcomes; health services; survivorship

DOI: 10.1002/cncr.32690