Multinational randomized clinical trial of specialist referral for cardiovascular risk in patients with prostate cancer

Patients with prostate cancer have a high burden of cardiovascular risk factors and adverse cardiovascular outomes. The randomized RADICAL PC trial, at 55 centers in 8 countries, investigated whether routine referral of patients with prostate cancer to a cardiovascular specialist to implement a systematic risk factor strategy is more likely to reduce adverse outcomes compared with usual care. The trial (2015-2025) included patients with prostate cancer diagnosed during the past 12 months, who had received androgen deprivation therapy (ADT) for the first time within the past 6 months or planned to start ADT in the next months. Patients taking a statin with a systolic blood pressure of 130 mm Hg or lower were ineligible. Patients were randomized 1:1 to receive usual care alone or usual care plus routine referral to an internist or cardiologist. The specialists provided a systemic intervention, including a target of systolic blood pressure of 130 mg or lower and a statin medication. Main outcome was a hierachical composite of cardiovascular death, myocardial infarction, stroke, heart failure, suboptimal cholesterol, and suboptimal blood pressure as evaluated by the win ratio. The analysis included 2487 patients with prostate cancer. During median follow-up of 5.8 years (IQR 2.7-8.2), the win ratio in favor of the intervention was 1.60 (95% CI 1.42-1.81), mostly attributable to lower cholesterol in the intervention group. There were no differences in time to cardiovascular death, myocardial infarction, stroke, or heart failure between the groups. The authors conclude that in this randomized trial, routine referral of patients with prostate cancer to a cardiovascular specialist resulted in improved outcomes, specifically through better cholesterol control. However, it is uncertain whether this reduced clinical cardiovascular events (visual abstract).