Assessment and stratification of cardiovascular disease risk in people diagnosed with breast cancer: A scoping review

Background: Breast cancer patients are at increased risk of cardiovascular disease, which often are associated with cardiotoxic breast cancer treatment or overlapping risk factors between the two diseases. Pre-treatment cardiovascular risk assessment can enable accurate risk stratification and prevention of cardiovascular disease. Several tools have been suggested, described or used in research to assess baseline (pre-treatment) risk to determine appropriate cardiovascular disease care before, during and after cancer treatment. This scoping review aims to identify and describe key features of baseline cardiovascular disease risk assessment tools for breast cancer patients. Methods: PubMed, Embase and Google Scholar were searched for articles published January 2013 – March 2024 to identify publications reporting cardiovascular disease risk assessment tools in breast cancer patients. Publications included research articles (observational and experimental studies) and position/policy, commentary and review papers. Eligibility was assessed and key data were extracted independently by two reviewers. Conflicts were discussed and resolved with the authorship team. Results: A total 144 articles were identified. Of these, 57 reported original data for the development, validation or recommendations of cardiovascular disease risk assessment tools and 87 reported the use of such tools. From these articles, 13 tools were identified that assessed the risk of cardiovascular disease broadly (n = 3) or death due to cardiovascular disease (n = 1) or specifically of cardiotoxicity or heart failure (n = 8) or venous thromboembolism (n = 1) in people diagnosed with breast cancer. Fourteen tools assessed cardiovascular disease risk in people diagnosed with mixed cancer types, including breast cancer. The planned development of four tools and/or surveillance pathways were described in protocol papers. Among all these tools identified (n = 31), seven tools (among these, four tools assessed people diagnosed with breast cancer only) went through external validation and performed poorly or moderately in stratifying cancer patients effectively into risk categories. Risk factors included in the assessment tools were age, breast cancer treatment type and pre-existing cardiovascular disease. While clinical guidelines and recommendations about baseline cardiovascular disease risk assessment were identified, these were either for cancer patients broadly or for cancer treatment types, and not specifically for people diagnosed with breast cancer. Conclusion: Several tools to assess baseline cardiovascular disease in people diagnosed with breast cancer were identified but only seven tools had gone through a validation process, and none were found to be very effective in differentiating people by baseline cardiovascular disease risk. Further work is needed to optimise the effectiveness of baseline cardiovascular disease risk assessments for breast cancer patients to enable appropriate stratification and monitoring of risk before, during and after treatment to improve cardiovascular health and outcomes.