Key result
Routine CV specialist referral yields ~75% greater benefit in prostate cancer patients with cholesterol >4 mmol/L.
Why the study?
It was unknown which patient subgroups with prostate cancer are more likely to benefit from routine cardiovascular care referral.
Does routine referral to a cardiovascular specialist improve cardiovascular outcomes in patients with prostate cancer?
RCT (n=2,487)
Randomized
Does routine referral to a cardiovascular specialist improve cardiovascular outcomes in patients with prostate cancer?
Patients with prostate cancer and uncontrolled modifiable cardiovascular risk factors, such as elevated cholesterol or blood pressure, derive the greatest benefit from routine cardiovascular specialist referral.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
““This important international study works to establish an evidence base of who benefits and how they may benefit from cardiovascular and internist management of risk,” said Bonnie Ky, MD, MSCE, FACC, editor-in-chief of JACC: CardioOncology.”
“This important international study works to establish an evidence base of who benefits and how they may benefit from cardiovascular and internist management of risk.”
“The major findings from this stratified analysis of a large, pragmatic, international, randomized controlled trial of a structured cardiovascular intervention for patients with prostate cancer are that more favorable intervention estimates were observed among participants with total cholesterol >4 mmol/L, self-reported hypertension or elevated baseline BP (systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), and possibly diabetes.”
Supports routine cardiologist referral for CV risk management during prostate cancer treatment; extends RCT evidence for integrated cardio-oncology care.
BACKGROUND: RADICAL PC-2 (RAndomizeD Intervention for CArdiovascular and Lifestyle Risk Factors in Prostate Cancer Patients) was a pragmatic randomized controlled trial that tested whether routine referral to a cardiologist or an internist for cardiovascular (CV) risk-factor and lifestyle modification improves outcomes in patients with prostate cancer or receiving androgen-deprivation therapy. The intervention group had more favorable outcomes overall, driven by improved cholesterol control, with no differences in rates of CV death, myocardial infarction (MI), stroke, or heart failure (HF). OBJECTIVES: The authors aim to identify patient subgroups more likely to benefit from routine CV care referral. METHODS: Prespecified subgroup analyses were used to assess whether patients at higher CV risk derived greater benefit from specialist referral, with treatment-effect heterogeneity assessed using interaction tests. The first primary outcome was a hierarchical composite of CV death, MI, stroke, HF, suboptimal cholesterol, and systolic blood pressure (SBP) control, evaluated using the win ratio. The second primary outcome was time to CV death, MI, stroke, or HF. RESULTS: Among 2487 participants, treatment effect differed by baseline total cholesterol ≤4 mmol/L vs >4 mmol/L (interaction P = 0.016), with respective win ratios of 1.21 (95% CI: 0.89-1.64) and 1.75 (95% CI: 1.51-2.03), and by baseline BP status (SBP ≥130 mm Hg or diastolic BP ≥80 mm Hg vs BP <130/80 mm Hg; interaction P = 0.003), with respective subdistribution HRs (sHRs) for CV death, MI, stroke, or HF of 0.86 (95% CI: 0.61-1.21) and 4.85 (95% CI: 1.65-14.26). The interaction for diabetes did not reach statistical significance (interaction P = 0.054) although the intervention effect estimates suggested a potential difference by diabetes status, with sHRs of 0.53 (95% CI: 0.24-1.15) among participants with diabetes and 1.25 (95% CI: 0.88-1.78) among participants without diabetes. The win ratio was higher among participants with total cholesterol >4 mmol/L, and sHRs were numerically lower among those with SBP ≥130 mm Hg or diastolic BP ≥80 mm Hg and diabetes. CONCLUSIONS: Uncontrolled modifiable CV risk factors may identify patients with prostate cancer who are more likely to benefit from routine CV care referral.
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Garcia et al. (2026) conducted an RCT in Prostate cancer (n=2,487). Routine referral to a cardiologist or an internist was evaluated on Hierarchical composite of CV death, MI, stroke, HF, suboptimal cholesterol, and systolic blood pressure control. Routine cardiovascular specialist referral provided greater benefit in prostate cancer patients with baseline total cholesterol >4 mmol/L (win ratio 1.75; 95% CI 1.51-2.03).
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