5 May 2021

Beating cancer but dying from CVD

Cardiovascular disease Clinical Death

Cancer survivors are at greater risk of dying than the general population in the years following diagnosis – and not from cancer, a study in the MJA shows.

A study by the University of South Australia and Flinders Medical Centre in Adelaide showed that cancer survivors were at higher risk of dying from non-cancer-related issues, particularly cardiovascular disease, compared with those in the general population.

The research tracked more than 32,600 people who were still alive at least five years after their diagnosis with cancer in the 90s.

The average age at diagnosis in the study was 60 and the median follow-up time was 17 years.

A total of 17,268 people died during the follow-up period, with half of deaths (7,845) attributed to cancer and half (9,423) attributed to non-cancer causes.

Ischaemic heart disease was the leading cause of death, followed by prostate cancer, cerebrovascular disease and breast cancer.

About 27% of deaths were due to cardiovascular disease.

The researchers compared the all-cause mortality rate in the cohort who had been diagnosed with cancer against the general population of South Australia and found it was higher in male patients, patients aged over 40 at diagnosis, among Aboriginal and Torres Strait Islanders, and for patients with multiple tumours.

An accompanying editorial by Professor Emily Banks, a public health physician and epidemiologist, and her colleague at ANU, epidemiology fellow Grace Joshy, pointed out the need to consistently provide “integrated, holistic and tailored long-term care, particularly primary care, for cancer survivors”.

“A key strategy for cancer survivorship is ensuring that best practice support for smoking cessation is consistently and universally provided,” they wrote.

“Smoking leads to large increases in all-cause mortality, including among people with cancer… While many smokers with cancer quit successfully, most continue to smoke after diagnosis.”


A version of this graph was included in the accompaning editorial. It shows the relative proportions of years of life lost because of fatal conditions, Australia, 2015; by disease and age group. Reproduced with permission from the Australian Institute of Health and Welfare.

Professor Michael Jefford, an oncologist and director of the Australian Cancer Survivorship Centre, said there was a narrow focus on testing for cancer recurrence at the moment.

Professor Jefford said it was important to find a balance between such testing and asking about other common medical issues survivors were dealing with, such as CVD, diabetes, depression, high blood pressure and so on. 

“In the oncology setting, we are focused on cancer. We need to broaden our focus and make sure we are managing risk factors and other co-morbid diseases,” he said.

Professor Jefford said a systemic model of shared care, where GPs and specialists work together on follow-up with patients, would improve survivor outcomes.

“There have been studies, including in Australia, that have looked at shared care, showing it is feasible, it is effective, it is cheaper, and patients like it,” he said.

“Cancer Australia has recommended shared care follow-up for people who have been treated for breast cancer, and endometrial cancer, and there are trials for prostate cancer.” 

Professor Michael Jefford

Professor Jefford said shared care would involve being clear on the role of GPs and oncologists during the follow-up process, and successfully incorporating a program to help people quit smoking and increase their exercise levels at the time of diagnosis, through treatment and beyond.

“If nobody is asking about smoking and nobody is asking about dealing with getting back to work, fatigue, sexuality, then we have a big, missed opportunity in care for survivors,” he said.

Professor Jefford hoped the huge uptake of telehealth during the COVID-19 pandemic would play a much bigger role in survivorship care, with conference calls between the oncologist, patient and GP being an effective way of sharing information.

In the meantime, oncologists could talk to their patients about common issues people experienced regardless of the type of cancer, as well as recommend resources by support groups such as the Cancer Council, Professor Jefford said.

Patients could be directed to the Australian Cancer Survivorship Centre website, where they could access a “Common Survivorship Issues Directory” and “Care Plan Generator”, which provided information on guidelines, an understanding of life after cancer and strategies to remain well. 

“I have no doubt over the next 10 years we are going to see much greater focus on shared care, and greater integration with primary care and emphasis on measuring outcomes for survivors – not that they just survived, but they have better quality of life,” Professor Jefford said.

MJA 2021, 19 April (print)