Population-Based Long-term Cardiac-Specific Mortality Among Patients With Major Gastrointestinal Cancers
Authors: Daryl Ramai, Joseph Heaton, Michele Ghidini, Saurabh Chandan, Mohamed Barakat, Banreet Dhindsa, Amaninder Dhaliwal, Antonio Facciorusso
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Patients with major gastrointestinal (GI) cancers are at long-term risk for cardiac disease and mortality. <h3>Objective</h3> To investigate the cardiac-specific mortality rate among individuals with major GI cancers and the association of radiation and chemotherapy with survival outcomes in the United States. <h3>Design, Setting, and Participants</h3> This US cohort study included individual patient-level data of men and women older than 18 years with 5 major gastrointestinal cancers, including colorectal, esophageal, gastric, pancreatic, and hepatocellular cancer from 1990 to 2016. Data was extracted from the Surveillance, Epidemiology, and End Results (SEER) national cancer database. Data cleaning and analyses were conducted between November 2020 and March 2021. <h3>Exposures</h3> Patients received chemotherapy, radiotherapy, or a combination of adjuvant therapy for major GI cancers. <h3>Main Outcomes and Measures</h3> The primary outcome was cardiac-specific mortality. Examined factors associated with cardiac mortality included age, sex, race, tumor location, tumor grade, SEER stage, TNM (seventh edition) staging criteria, cancer treatment (ie, the use of radiation, chemotherapy, or surgery), survival months, and cause of death. <h3>Results</h3> A total of 359 032 patients (mean [SD] age at baseline, 65.1 [12.9] years; 186 921 [52.1%] men) with GI cancers were analyzed, including 313 940 patients (87.4%) with colorectal cancer, 7613 patients (2.1%) with esophageal cancer, 21 048 patients (5.9%) with gastric cancer, 7227 patients (2.0%) with pancreatic cancer, and 9204 patients (2.6%) with hepatocellular cancer. Most cancers were localized except pancreatic cancer, which presented with regional and distant involvement (3680 cancers [50.9%]). Overall, all major gastrointestinal tumors were associated with increased risk of cardiac mortality compared with noncardiac mortality (median survival time: 121 [95% CI, 120-122] months vs 287 [95% CI, 284.44-290] months). Patients with hepatocellular cancer had the lowest cardiac-specific median survival time (98 [95% CI, 90-106] months), followed by pancreatic cancer (105 [95% CI, 98-112] months), esophageal cancer (113 [95% CI, 107-119] months), gastric cancer (113 [95% CI, 110-116] months), and colorectal cancer (122 [95% CI, 121-123] months). At 15 years of follow up, the use of only chemotherapy, only radiation, or radiation and chemotherapy combined was associated with poor survival rates from cardiac causes of death (eg, colorectal: chemotherapy, 0 patients; radiation, 1 patient [1.9%]; radiation and chemotherapy, 3 patients [2.7%]). <h3>Conclusions and Relevance</h3> These findings suggest that among patients with major gastrointestinal cancers, cardiac disease is a significant cause of mortality. The use of only chemotherapy, only radiation, or both was associated with higher cardiac mortality.