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Addressing cardiovascular risks with a goal to prevent cardiovascular complications in patients undergoing antihormonal therapy for prostate cancer

Cardio-Oncology volume 11, Article number: 31 (2025) Cite this article

Abstract

Over 1 million cases of prostate cancer are reported every year, and it is the second most common cancer in men. Androgen deprivation therapy (ADT) is a hallmark treatment for prostate cancer but is associated with the development or exacerbation of cardiovascular disease. The most common cause of non-cancer death in patients with prostate cancer is cardiovascular disease. Thus, a better understanding of the prevalence of cardiovascular toxicity across all therapies, management of potential cardiovascular complications, and prevention of cardiovascular events is essential as treatments continue to evolve. In this article, the first in a 2-part series, we provide a review of the current landscape of ADT therapy and its association with cardiovascular disease, summarize recent clinical trial data evaluating cardiovascular outcomes, and provide insights on the management of cardiovascular risk factors and adverse events for clinicians managing this high-risk population of men undergoing potentially cardiotoxic treatment for prostate cancer.

Introduction

Prostate cancer remains the second most common cancer in men, with over 1 million reported cases every year [1].However, among patients with prostate cancer, the most common cause of non-cancer related death is atherosclerotic cardiovascular disease (ASCVD) [1]. Cardiovascular events have also been linked to the use of androgen deprivation therapy (ADT), a cornerstone treatment for advanced prostate cancer that may be prescribed for up to half of patients during their disease course [2]. Understanding the prevalence of cardiovascular risk factors, cardiovascular toxicities related to prostate cancer therapy, management of cardiovascular complications, and prevention of cardiovascular events is of utmost importance to improve outcomes in prostate cancer.

Prostate cancer, although serious, has an excellent prognosis overall, with more than 97% of patients surviving more than 5 years after diagnosis. However, there are currently an estimated 3.1 million prostate cancer survivors today with a high rate of pre-existing cardiovascular disease or cardiovascular risk factors (hypertension, type 2 diabetes, and hyperlipidemia) when compared with patients with other cancers [3]. Thus, the optimal management of these patients requires close coordination among cardiologists, oncologists, urologists, and primary care providers. Recognizing this need, in 2010, the American Heart Association (AHA), American Cancer Society (ACS), and American Urological Association (AUA) issued a science advisory; nonetheless, significant further efforts are required [4].

In an effort to raise awareness and make practical suggestions about how practitioners can effectively collaborate, the International Cardio-Oncology Society (IC-OS), in conjunction with the European Association of Urology (EAU) and the Canadian Urology Association (CUA), developed a webinar series in 2022 to review and develop strategies to anticipate cardiovascular toxicities related to prostate cancer treatment with the hope that early recognition and optimal management strategies would allow the most effective cancer therapy to be delivered to the largest number of men with prostate cancer. This review will concisely summarize the presentations and data discussed throughout.

Review

Prevalence of cardiovascular disease in patients with prostate cancer

Patients with advanced prostate cancer typically have a higher-than-expected rate of cardiovascular disease when compared with the general population [2, 5]. For instance, a population-based observational study of 185,106 men with local/regional prostate cancer examined preexisting cardiovascular risk factors or a prior cardiovascular event and found that about 4% had prior myocardial infarction, 31% had hypertension, 20% had congestive heart failure, and 17% had some form of stroke [6]. Furthermore, those undergoing ADT were at higher risk of myocardial infarction (adjusted hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.02–1.16) and diabetes (adjusted HR 1.33; 95% CI 1.27–1.39) [6]. In another study of 37,443 men with localized prostate cancer from the Veterans Healthcare Administration, investigators found increased incidences of diabetes (adjusted HR 1.28; 95% CI 1.19–1.38), coronary heart disease (adjusted HR 1.19; 95% CI 1.10–1.28), myocardial infarction (adjusted HR 1.28; 95% CI 1.08–1.52), sudden cardiac death (adjusted HR 1.35; 95% CI 1.18–1.54), and stroke (adjusted HR 1.27; 95% CI 1.10–1.36) in patients on ADT compared with those not on ADT [7]. In a retrospective study of 354 patients with prostate cancer, incidental coronary calcification on PET/CT was associated with a significant incidence of MACE (21%) [8]. In a cross-sectional analysis of over 90,000 US veterans with prostate cancer from 2010 to 2017, the rates of incomplete cardiovascular risk factor assessments remained high. The study revealed significant gaps in comprehensive cardiovascular risk assessment, with more than 1 in 5 veterans not receiving complete evaluations. There were notable deficiencies in lipid screening, diabetes assessment, and obesity evaluation [9]. These studies highlight the importance of assessing cardiovascular risk in patients being considered for ADT.

How androgen deprivation therapy impacts the cardiovascular system

ADT, which suppresses testosterone synthesis, has been a cornerstone of management of metastatic prostate cancer since its landmark discovery by Charles Huggins and Clarence Hodges in 1941, and it has been increasingly used as neoadjuvant therapy for radiation therapy. As androgens are the major stimulus of prostate cancer growth, ADT impedes the progression of advanced prostate cancer (Fig. 1). While ADT may be delivered by bilateral orchiectomy, surgical castration has largely been supplanted by pharmacologic castration using gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonists [10]. GnRH agonists stimulate the anterior pituitary gland on a continuous basis. While this initially leads to a surge in luteinizing hormone, follicle-stimulating hormone, and testosterone, the continuous stimulation of the pituitary (as distinct from pulsatile physiologic stimulation) leads to the suppression of luteinizing hormone, follicle-stimulating hormone, and testosterone within days to weeks [10]. To mitigate the initial testosterone surge observed with GnRH agonist use, antiandrogens are often administered with GnRH agonists early in the treatment course. In contrast to GnRH agonists, GnRH antagonists directly inhibit the effects of GnRH on the anterior pituitary, leading to immediate suppression of luteinizing hormone, follicle-stimulating hormone, and testosterone [10, 11].

Fig. 1
figure 1

Androgen deprivation therapy and mechanisms of testosterone suppression

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Despite the effectiveness of the above therapies in treating prostate cancer, they also physiologically increase cardiovascular risk. For instance, ADT is linked to a diminution in lean body mass with an increase in fat mass [12, 13]. ADT also increases total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglycerides [13, 14]. Furthermore, ADT can increase insulin resistance, a mechanism thought to explain the high incidence of type 2 diabetes in patients on therapy [15, 16]. Additionally, low levels of testosterone have been associated with decreased arterial compliance and increased arterial stiffness leading to hypertension [17, 18]. All together these therapies can lead to the destabilization of atherosclerotic plaque [19].

There have been a few studies comparing types of ADT such as GnRH agonists, antiandrogens, orchiectomy, combined androgen blockage, and GnRH antagonist. One study found GnRH agonists to have higher cardiovascular risk than orchiectomy (HR 1.21; 95% CI 1.18–1.25 vs HR 1.16; 95% CI 1.08–1.25) [2]. A French observational study showed a higher risk of ischemic stroke and myocardial infarction in patients who received combination androgen blockade (adjusted HR 1.61; 95% CI 1.27–2.03) and decreased risk in those with antiandrogen monotherapy (adjusted HR 0.61; 95% CI 0.43–0.88) [20]. Table 1 shows a list of cardiovascular complications associated with various types of therapies.

Table 1 Antihormone therapies for prostate cancer and their associated cardiovascular complications
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Clinical trial data comparing the cardiovascular outcomes of various types of ADT remain scarce. A meta-analysis of phase III randomized clinical trial data of the GnRH antagonist degarelix compared with a GnRH agonist reported fewer adverse effects with GnRH antagonist [21]. Novel agents such as the androgen biosynthesis inhibitor abiraterone and the androgen receptor signaling inhibitor enzalutamide were found to have higher rates of hypertension and a 36% increased risk of cardiovascular events compared with placebo [22]. Furthermore, a randomized clinical trial comparing continuous ADT with intermittent ADT showed similar rates of adverse cardiovascular events, suggesting that timing of the initial ADT use correlated most with cardiovascular risk [23].

Insights from PRONOUNCE

More recently, the PRONOUNCE study compared the GnRH antagonist degarelix with the GnRH agonist leuprolide in patients with prostate cancer and established atherosclerotic cardiovascular disease [24]. PRONOUNCE was the first international, multicenter, prospective, randomized open-label trial in which participants were randomly assigned 1:1 to receive degarelix or leuprolide for 12 months. The primary outcome was time to first major adverse cardiovascular event (composite of death, myocardial infarction, or stroke). A total of 545 patients across 12 counties were enrolled. The median age was 73 years; about 50% had localized prostate cancer, 26% had locally advanced disease, and 20% had metastatic disease [24]. Due to slower-than-expected enrollment and fewer-than-projected primary outcome events, enrollment in the trial was stopped before the 900 planned participants accrued. In this setting, adverse cardiovascular events occurred in 5.5% of patients assigned to degarelix and 4.1% assigned to leuprolide (HR 1.28; 95% CI 0.59–2.79; p = 0.53) [24]. Despite there being no difference in the primary outcome at one year, the question of the relative cardiovascular safety of a GnRH antagonist compared with a GnRH agonist remains unresolved given the early discontinuation of enrollment. Furthermore, there was no difference in oncologic outcomes such as time to death, radiographic disease progression, introduction of additional prostate cancer therapies, prostate-specific antigen (PSA) test failure, or testosterone levels [24]. There is a need for rigorously conducted cardio-oncology trials to better define the cardiovascular risk of new cancer agents. PRONOUNCE provides a model for interdisciplinary collaboration among urologists, oncologists, and cardiologists with a shared goal of evaluating the impact of cancer therapies on cardiovascular outcomes.

Benefits of ADT and ADT adjuncts in oncologic outcomes

Despite the cardiovascular risks associated with ADT, there are very clear oncologic benefits in prostate cancer, with novel agents on the horizon. For locally advanced disease, ADT can serve as adjuvant therapy with radiation (for high-risk disease) or post-operative adjuvant therapy if there are positive lymph nodes. ADT has also been shown to be helpful in patients with biochemical recurrence or PSA elevation who are otherwise asymptomatic but have a prior history of prostate cancer. Furthermore, ADT can be used in metastatic disease as palliative therapy to prevent severe complications and prolong life [25]. Therapies also need to be tailored to individual patient’s needs, risk, and benefits, as real world populations differ from participants in clinical trials, which often exclude individuals with visceral metastatic disease or other poor prognostic factors [26, 27].

Many ADT adjuncts or antiandrogens have also shown survival benefits across a spectrum of patients with prostate cancer. For instance, the multicenter, international, randomized clinical trial LATTITUDE compared abiraterone acetate (an androgen biosynthesis inhibitor) plus prednisone with placebo in combination with ADT in patients with metastatic, castration-sensitive prostate cancer. The investigators found a significant benefit in survival in the intervention arm compared with the control (HR 0.62; 95% CI 0.51–0.76) [28]. The androgen receptor inhibitor enzalutamide also showed benefit compared with standard nonsteroidal antiandrogen therapy in patients with metastatic hormone-sensitive prostate cancer who underwent testosterone suppression. Specifically, there was improved overall survival (HR 0.67 l; 95% CI 0.52–0.86), PSA progression-free survival (HR 0.39; 95% CI 0.33–0.47), and clinical progression-free survival (HR 0.40; 95% CI 0.33–0.49) [29]. Additionally, the androgen receptor inhibitor apalutamide also showed a survival benefit compared with placebo in patients on ADT therapy with metastatic, castration-sensitive prostate cancer (HR 0.67; 95 CI 0.51–0.89) [30]. These therapies for prostate cancer have also shown a survival benefit for patients in advanced prostate cancer disease states such as non-metastatic castration-resistant and metastatic castration-resistant prostate cancer [31,32,33,34,35,36,37].

The appropriate length of time for combining ADT with high-dose radiotherapy for prostate cancer is a topic of ongoing debate. Recent studies such as DART and SPPORT offer valuable insights, suggesting that restricting the duration of ADT to 18 months might be the most favorable approach [38, 39]. Further, the utilization of molecular imaging for guiding decisions and planning treatments in prostate cancer is on the rise [40].

Management and prevention of cardiovascular disease

The American College of Cardiology (ACC) and AHA have released guidelines on the prevention of cardiovascular disease that may be helpful for clinicians [41]. Furthermore, the AHA has many patient-level educational resources available online (www.heart.org) that can help patients remain engaged in their overall health. To help patients and providers remember some of the cornerstone concepts in maintaining heart health, the AHA has introduced “Life’s Essential 8,” which include having a healthy diet, maintaining physical activity, avoiding nicotine, having good sleep habits, maintaining a healthy weight, controlling cholesterol, controlling blood glucose, and controlling blood pressure [42]. Addressing these components in a patient-centered, team-based and shared decision making capacity can help optimize cardiovascular health. A summary of Life’s Essential 8 and cardiovascular prevention strategies are presented in Table 2.

Table 2 AHA’s Life’s Essential 8 and ACC/AHA guideline-based recommendations [40] for cardiovascular health
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Heart healthy diet and nutrition

Current ACC/AHA guidelines recommend a diet that emphasizes the intake of vegetables, fruits, legumes, nuts, whole grains, and fish [41]. Furthermore, the replacement of saturated fats and trans fats with monounsaturated or polyunsaturated fats is recommended. Minimizing intake of processed meats, refined carbohydrates, sweetened beverages, cholesterol, and sodium can also reduce ASCVD risk [41]. Plant-based and Mediterranean diets have been shown in observational studies to reduce cardiovascular events [43, 44]. A recent systematic review that analyzed 32 publications including 5 interventional and 11 observational studies demonstrated short-term improvements in prostate cancer progression with a plant-based diet [45]. The PREDIMED (Prevencion con Dieta Mediterranea) trial compared a Mediterranean diet (supplemented with extra virgin olive oil or nuts) with low-fat diet in patients at high cardiovascular risk. The investigators found a reduction (30% with extra virgin olive oil and 28% with nuts) in the combined endpoint of myocardial infarction, stroke, and cardiovascular mortality [46]. Another analysis showed that more vegetable consumption compared with animal protein was associated with a higher mortality reduction [47]. The relationship between dairy consumption and the risk of prostate cancer has been subject to conflicting evidence. A prospective study from 2001 found that men who drank more than two glasses of milk daily had a higher risk of advanced prostate cancer compared with those who consumed less milk [48]. However, more recent systematic reviews indicate that the evidence is inconclusive [49], and no definitive conclusions can be drawn at this time.

Physical activity

There continues to be a rise in sedentary behaviors in Western societies. Life stresses, sedentary jobs, remote workplaces, unwalkable neighborhoods, and limited access to gyms are some of the many reasons to consider when determining ways patients can get more exercise. To make matters worse, patients on ADT are at high risk of loss of muscle mass, osteoporosis, metabolic syndrome, and diabetes [50]. In a prospective study involving 1455 men diagnosed with localized prostate cancer, men who walked briskly for ≥ 3 h per week had a 57% lower rate of progression than men who walked at an easy pace for < 3 h per week (HR 0.43; 95% CI 0.21–0.91; p = 0.03) [51]. Current guidelines recommend at least 150 min per week of moderate-intensity exercise (achieving 3–5.9 metabolic equivalents [METs]) or 75 min per week of vigorous-intensity exercise (≥ 6 METs) to reduce ASCVD risk [41]. Unfortunately, about half of adults in the United States do not meet the minimum physical activity recommendations [52]. There are currently no specific recommendations with regard to minimum physical activity in patients diagnosed with prostate cancer.

Treatment of tobacco use

Smoking has been shown to have a significant impact on prostate cancer outcomes. Smoking at the time of diagnosis is associated with higher rates of disease recurrence, increased prostate cancer-specific mortality, and overall mortality [53]. Tobacco cessation is of upmost importance in reducing both cardiovascular and oncologic risk. The ACC/AHA recommend that all adults who smoke should be firmly advised to quit [41]. Early interventions with either behavioral therapies or pharmacotherapy are recommended to maximize quit rates [54, 55]. Furthermore, secondhand smoke is shown to increase ASCVD risk, and exposure should be avoided. E-cigarettes and vaping also share similar risks [56, 57].

Many institutions have smoking cessation programs that can be very helpful and often feature personalized strategies to help patients quit. In addition, there are a variety of nicotine replacement therapies including patches, gums, lozenges, nasal sprays, and inhalers. Other pharmacologic therapies include bupropion and varenicline [41].

Healthy sleep habits

Patients undergoing ADT frequently experience fatigue and sleep disturbances, which can negatively impact their quality of life and lead to reduced adherence to treatment [58]. There is increasing evidence to indicate that poor sleep can contribute to adverse cardiovascular outcomes [59]. Inadequate sleep (< 7 h) or interrupted sleep has been associated with diabetes, obesity, and hypertension [59, 60]. Patients with established cardiovascular disease were found to have high cardiovascular mortality with poor sleep patterns [61]. Poor sleep patterns can often be modified by practicing better sleep hygiene, including going to bed and waking up at the same time every day of the week, avoiding exposure to screens before going to bed, ensuring a comfortable temperature in the bedroom, making sure the room is dark, and avoiding stimulants or alcohol right before bedtime [59]. Poor sleep patterns may also be a sign of undiagnosed sleep apnea. Thus, providers should inquire about patient’s sleep habits, as these could be another way to help improve overall cardiovascular risk.

Management of weight and obesity

There is a growing body of research that suggests that weight loss after a diagnosis of prostate cancer may be beneficial for both overall survival and prostate cancer-specific survival. One ACS study that followed nearly 12,000 men for an average of 11 years found that men who gained more than 5% of their body weight or more than 10 pounds after a diagnosis of localized prostate cancer were more likely to die of prostate cancer and all causes than men who maintained their weight [62].

There are not enough data to suggest that weight loss after prostate cancer diagnosis improves mortality. It is thought that weight loss may help reduce inflammation, improve insulin sensitivity, and decrease the production of testosterone, all of which may play a role in the development and progression of prostate cancer; however, weight loss can improve cardiovascular outcomes.

The ACC/AHA as well as several other obesity management societies recommend early enrollment in comprehensive lifestyle programs that promote weight loss, assist in caloric restriction (800–1500 kcal/day, if safe), and promote physical activity with frequent follow-up or check-ins [41]. The recommended physical activity level for weight loss is between 200–300 min a week if able. Many pharmaceutical therapies can also assist with weight loss, particularly glucagon-like peptide 1 receptor agonists (GLP1-RA) in patients who also have type 2 diabetes [63]. It is important to remember that even ≥ 5% of initial weight loss can result in moderate improvement of blood pressure, cholesterol, and blood glucose [41]. The importance of having a nutritionist can also not be understated.

Adults with elevated cholesterol

When a person is diagnosed with cancer, their focus often shifts from long-term health management to more acute management of the cancer. As a result, other chronic conditions, such as atherosclerotic disease, may be deprioritized. There is mixed evidence on the impact of statins on cancer-specific mortality. Most meta-analyses suggest either no effect or minimal effect on cancer-specific mortality [64,65,66]. However, it is important to recognize that patients diagnosed with cancer are more likely to be overweight or obese and have a history of smoking, which increases their risk of cardiovascular disease. To make matters worse, ADT is associated with metabolic syndrome and increased cardiovascular mortality [67]. According to expert consensus, continued monitoring of lipid profiles per ACC/AHA guidelines and the continuation of lipid-lowering agents are recommended. The ACC/AHA guidelines recommend that cancer survivors have their lipid levels checked at least every year [68].

Adults with type 2 diabetes mellitus

Type 2 diabetes is a major risk factor for ASCVD and widely prevalent in the United States. Approximately 12% of adults in the United States have diabetes, primarily type 2 diabetes, and more than one-third of the population has pre-diabetes [41]. ADT has also been shown to be associated with the development of diabetes, making the identification and management of diabetes very important in reducing cardiovascular risk. Type 2 diabetes is defined by a hemoglobin A1c level of ≥ 6.5%, with the general goal being to maintain it below 7% for optimal glycemic control. However, specific recommendations for managing diabetes in patients with prostate cancer are lacking [41]. In addition to counseling patients to follow a heart healthy diet and recommending guideline-based physical activity requirements, patients may benefit from the addition of pharmacotherapy. The first treatment is typically metformin to improve glycemic control; however, in patients with heart failure, established ASCVD, or obesity, the use of sodium glucose cotransporter 2 (SGLT2) inhibitors or GLP1-RA has proven to be of significant benefit in reducing cardiac events [69,70,71]. Not all providers are familiar with the myriad pharmacotherapies for diabetes; therefore, collaboration with a cardiometabolic and/or endocrine specialist is encouraged.

Adults with elevated blood pressure

Chemotherapy is an independent risk factor for hypertension due to the direct effects on endothelial function, sympathetic activity, and renin-angiotensin system activity. Additionally, some chemotherapeutic agents can be nephrotoxic, which can also lead to hypertension. Adequate blood pressure management often requires a combination of nonpharmacologic and pharmacologic therapies [41]. Nonpharmacologic therapies include weight loss, following a heart healthy diet, sodium restriction, dietary potassium supplementation, increased physical activity, and limiting alcohol consumption. Pharmacologic therapy is also recommended in addition to nonpharmacologic therapy if blood pressure is ≥ 140/90 mmHg or ≥ 130/ ≥ 80 mmHg with a 10-year ASCVD risk calculated at ≥ 10% [41]. In general, a reasonable blood pressure goal according to the ACC/AHA guidelines is < 130/ < 80 mm Hg [41]. Blood pressure taken in clinic may not be accurate either due to “white coat hypertension” (possibly due to anxiety about the visit) or “masked” hypertension (values in the clinic setting are normal but are elevated in home environments). In these cases, home blood pressure monitoring can be helpful to determine how aggressively high blood pressure should be treated. This is especially true for patients on ADT or antiandrogen therapy, whose risk of developing elevated blood pressure is already high.

Conclusion

Patients diagnosed with prostate cancer often have significant baseline cardiovascular risk factors that are frequently overlooked during cancer diagnosis. Additionally, cancer therapies can be associated with cardiovascular toxicity. There are many ways providers can manage and prevent cardiovascular complications in men undergoing potentially cardiotoxic treatment for prostate cancer. Close collaboration with cardiometabolic and cardio-oncology specialists will be key to ensure cardiovascular health is optimized. The risks and benefits of prostate cancer treatment must always be considered, especially if patients are at high-risk for cardiovascular events. Despite great insights from the PRONOUNCE trial, more research, particularly randomized clinical trial data focused on cardiovascular outcomes, is certainly warranted as therapeutics for prostate cancer continue to evolve. Including cardiovascular specialists in tumor board discussions will also be important to investigate in the future. In the meantime, remembering the AHA’s Life’s Essential 8 and referring to the current ACC/AHA prevention guidelines will help both providers and patients promote heart-healthy living.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ACC:

American College of Cardiology

ACS:

American Cancer Society

ADT:

Androgen deprivation therapy

AHA:

American Heart Association

ASCVD:

Atherosclerotic cardiovascular disease

AUA:

American Urological Association

CI:

Confidence interval

CUA:

Canadian Urology Association

EAU:

European Association of Urology

GnRH:

Gonadotropin-releasing hormone

HR:

Hazard ratio

IC-OS:

International Cardio-Oncology Society

LDL-C:

Low-density lipoprotein cholesterol

MET:

Metabolic equivalent

PSA:

Prostate-specific antigen

SGLT2:

Sodium glucose cotransporter 2

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Acknowledgements

Diana Steele-Jones and Elizabeth E.S. Cook, both of the Duke Clinical Research Institute, provided editorial assistance.

Funding

The webinar series was funded by Ferring Pharmaceuticals; there was no external funding for the manuscript.

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Authors and Affiliations

  1. Duke Clinical Research Institute, P.O. Box 17969, Durham, NC, 27715, USA

    Nishant P. Shah & Renato D. Lopes

  2. Division of Cardiology, East Carolina University, Greenville, NC, USA

    Avinash Singh & Filipe Cirne

  3. Department of Urologic Sciences at the University of British Columbia, Vancouver, BC, Canada

    Tia Higano

  4. Martini-Klinik Prostate Cancer Center and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Derya Tilki

  5. Division of Urology, University of Toronto, Toronto, ON, Canada

    Neil Fleshner

  6. Harvard Medical School, Boston, MA, USA

    Paul Nguyen

  7. Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK

    Chris Plummer

  8. Hospital Clínico San Carlos, Madrid, Spain

    Juan Gomez Rivas

  9. Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA

    Kathleen Zhang

  10. Department of Urology, Dalhousie University, Halifax, NS, Canada

    Ricardo Rendon

  11. Dana-Farber Cancer Institute, Boston, MA, USA

    Alicia Morgans

  12. Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Canada

    Darryl Leong

  13. International Cardio-Oncology Society, Tampa, FL, USA

    Daniel Lenihan

  14. St. Francis Healthcare, Cape Cardiology, Cape Girardeau, MO, USA

    Daniel Lenihan

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  1. Nishant P. Shah
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Shah, N.P., Singh, A., Higano, T. et al. Addressing cardiovascular risks with a goal to prevent cardiovascular complications in patients undergoing antihormonal therapy for prostate cancer. Cardio-Oncology 11, 31 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40959-025-00318-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40959-025-00318-5

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Cardio-Oncology

ISSN: 2057-3804

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