Nearly 10,000 cases of endometrial cancer are diagnosed in the UK each year. But for patients who survive their cancer, cardiovascular disease poses an additional and ongoing risk, accounting for a quarter of all deaths in endometrial cancer survivors. In this piece, published as part of the Healthy Hearts collection on cardiovascular health, Dr Heather Agnew, Dr Sarah Kitson, and Professor Emma Crosbie explain how a more targeted approach to tackling cardiovascular disease in cancer survivors could improve health outcomes, including for women from the most deprived socio-economic groups.

• Nearly 90% of endometrial cancer survivors have at least one undiagnosed or undertreated cardiovascular risk factor, with several factors common to both cancer and cardiovascular disease.
• A cancer diagnosis presents a ‘teachable moment’, where patients can be provided with personalised advice and support.
• To ensure support is maintained, a joined-up approach to CVD screening in endometrial cancer survivors is needed between primary and secondary care services.

Endometrial cancer is the fourth most common cancer in women in high income countries, with nearly 10,000 cases diagnosed every year in the UK alone. The incidence of the disease has doubled in the last 20 years, with this trajectory expected to continue. Despite relatively good survival outcomes compared to other cancers, individuals with a history of endometrial cancer have a higher risk of death than those without. Within this group, cardiovascular disease (CVD) is a significant risk.

Previous research from The University of Manchester found endometrial cancer survivors have a higher prevalence of undiagnosed and untreated cardiovascular risk factors than the general population, including high blood pressure and high cholesterol. This is perhaps to be expected, given that endometrial cancer and CVD share the common risk factors of obesity and diabetes. Indeed, women with diabetes have twice the risk of endometrial cancer compared to non-diabetic women, even after controlling for the effects of body weight, suggesting a close relationship between the two conditions.

However, despite the known association, screening and interventions for cardiovascular risk factors are not routinely undertaken in endometrial cancer survivors, meaning the true prevalence of CVD risk factors in this group is likely higher than previous estimates suggest. The findings of research led by the Manchester group support this, with screening of a cohort of endometrial cancer survivors finding 57% had previously undiagnosed diabetes or hyperglycaemia (high blood sugar), compared to just 11.5% of a control group. Within the same group, 89% of cancer survivors had undiagnosed or undertreated CVD risk factors, compared to 54% of controls. 22% of the survivors had three or more CVD risk factors.

Now, new findings show that 5+ years post-diagnosis, CVD is one of the leading causes of death for endometrial cancer survivors, accounting for 1 in 4 deaths.

Utilising the teachable moment of a cancer diagnosis, researchers at Manchester have conducted a study to assess cardiovascular risk in individuals with a history of endometrial cancer, and then provide these individuals with tailored advice on reducing their risk. 80 individuals with a history of endometrial cancer participated in the study, of whom 18% were of Asian or Black ethnicity, and 34% were from the most deprived socio-economic backgrounds.

All of the participants had at least one potentially modifiable CVD risk factor, with an average of four. After this risk assessment, each participant was then given tailored lifestyle advice and NICE recommended pharmacotherapy, alongside their routine cancer follow-up. At 12 months, 45% had successfully instigated some or all of the recommended changes, with 23% successfully implementing half or more of the changes recommended to them to target their cardiovascular health.

While a positive step, it was important to understand why over three quarters of participants were unable to implement more than half of the recommended changes. Through interviews, they identified barriers and facilitators to implementing lifestyle changes. The challenges they faced included pre-existing health conditions, family, age, lack of knowledge, money, time, fixed mindset, and poor relationships with healthcare providers. The cost of healthy food and gym memberships were particular barriers for those from more deprived socio-economic groups.

Another common theme was the lack of individualised support, with generic information not appropriate for participants with underlying health problems, or non-Western dietary preferences.

Of the facilitating factors, perceived benefits to overall health and family were strong motivators for change, alongside a desire for independence in daily living and the impact of seeing results. Clear advice and information which promoted knowledge and awareness, alongside a good patient-healthcare provider relationship, were important facilitators of change.

Policy recommendations

Health policy must reflect that endometrial cancer survivors are at high risk of cardiovascular disease. There is a window of opportunity when these individuals are undergoing follow-up in which their cardiovascular risk factors can be targeted and treated, to potentially reduce preventable deaths. Barriers to making these changes reveal inequalities in survivorship care, and these changes must be addressed with consideration of diverse backgrounds, physical capabilities and socioeconomic context.

As such, routine screening for CVD in individuals with a history of endometrial cancer should be a shared responsibility of both primary and secondary care. Introduction of this screening, and subsequent interventions for cardiovascular risk factors in women following treatment for endometrial cancer, would be more effective than a similar programme aimed at the general population.

For those where risk factors are identified, individualised support to make lifestyle changes should be offered, including dietary and physiotherapy input, plus education on cardiovascular health in this context for both patients and healthcare providers. There is a role for social prescribing link workers in connecting at-risk patients to community-based support, as well as health and wellbeing coaches in setting and maintaining behaviour change goals.

Being diagnosed with cancer is a highly emotional experience, which inevitably leads to questions about risk and prevention. Treating this as a teachable moment presents an opportunity for discussions about cardiovascular risk; arguably, this is more important than the efforts made in routine follow-up to identify recurrent disease in women who have generally been cured of their endometrial cancer. Weight loss is an obvious intervention to reduce the risk of both CVD and cancer, but one that is difficult to sustain by dietary restriction and lifestyle change. Instead, health policymakers should adopt a strategy of identifying and improving undiagnosed or undertreated cardiovascular risk factors, with appropriate drug therapy one reasonable alternative.

The Health Mission adopted by the government includes goals to prioritise women’s health, as well as moving to a more preventative model of healthcare. A cardiovascular screening programme in endometrial cancer survivors captures both of these objectives. The evidence on the risk of cardiovascular disease to these patients is clear: now is the time to act on it.