Cardiovascular Risk Assessment in Prostate Cancer: The Role of Coronary Artery Calcium Scoring

Cardiovascular disease (CVD) and cancer are leading global causes of morbidity and mortality [1, 2], with many older adults managing both conditions simultaneously [3]. Prostate cancer, the second most frequent malignancy in men [4], brings distinct concerns due to the way treatments can aggravate cardiovascular risk [5]. Androgen deprivation therapy (ADT), in particular, can induce metabolic changes that heighten the likelihood of coronary artery disease, stroke, and other vascular events [6]. As more effective cancer therapies improve survival, the importance of thorough cardiovascular assessment has grown. Identifying at-risk patients early enables clinicians to consider interventions such as statins, antihypertensives, and lifestyle support.Against this backdrop, a recent study by Stødkilde-Jørgensen [7] adds new evidence for the prognostic usefulness of coronary artery calcium scores (CACS) acquired from non-cardiac routine computed tomography (CT) scans. Incorporating CACS into standard care might offer a practical method to detect men who may benefit from recommended risk reduction measures. It illustrates the expanding intersection of cardiology and oncology, where recognition of shared risk factors and dual disease management increasingly shapes clinical practice.The study provides evidence that CACS, obtained from non-electrocardiogram-gated CT scans during prostate cancer staging, predicts adverse cardiovascular outcomes. The key finding – that patients with a high CACS (≥400) face a threefold increased risk of death, myocardial infarction, or stroke – shows the potential of integrating CACS into routine care. This approach aligns with the broader goal of improving survivorship in cancer patients by addressing cardiovascular comorbidities [8], especially since prostate cancer patients benefit from effective treatments and now live longer than ever. Prostate cancer is projected to double globally from 1.4 million cases per year in 2020 to 2.9 million by 2040, transforming it into a chronic condition that patients often live with rather than die from. Given the increasing prevalence and extended survival of prostate cancer patients, CVD remains a critical comorbidity. Hence, the need for primary prevention strategies to mitigate cardiovascular risk, including the incorporation of CACS into routine care pathways [5, 9].Using prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) scans for CACS determination is a practical approach, where existing imaging data without additional procedures or costs can be used. In the study by Stødkilde-Jørgensen [7], stratifying patients into CACS groups allowed them to identify those at highest risk and prioritize preventive interventions (Fig. 1). The study’s use of a large cohort, matched controls, and adjusted analyses ensures reliable and generalizable results within its regional context. However, the predominantly Caucasian population and exclusion of patients with advanced disease stages may limit the study’s generalizability. Missing information on smoking, cancer stage, and body mass index reduces the precision of risk estimates. Additionally, including all-cause mortality in the composite endpoint makes it difficult to isolate cardiovascular-specific risks.Incorporating CACS into routine prostate cancer care could help bridge a notable gap in preventive strategies. By identifying high-risk individuals, clinicians have an opportunity to prescribe measures such as therapeutic lifestyle modifications, aggressive risk factor modification and judicious use of statin therapy, aspirin, or enhanced monitoring to lower cardiovascular risk. Nonetheless, the finding that only 53% of those with CACS ≥400 were on statins suggests a missed chance to reduce adverse events. This indicates that clearer guidelines and more robust clinical pathways are needed to ensure consistent preventive treatment for at high-risk patients.Additionally, the relative ease of deriving CACS from existing imaging sets it apart as a cost-effective option in healthcare systems operating under financial or logistical constraints. However, integrating CACS into standard clinical workflows depends on resolving obstacles like radiologist training and the adoption of compatible software for data collection and interpretation. In many settings, oncologists and cardiologists may not be fully aware of the utility of CACS, yielding the need for targeted education and updated guidelines.Collaboration across specialties is vital to making CACS assessments a norm in prostate cancer management. Cardio-oncology programs or shared-care arrangements offer a structure where cardiovascular risk can be evaluated and managed alongside cancer treatment. By incorporating tools like CACS, these models stand to improve outcomes through earlier detection of cardiovascular problems and swift intervention when needed.Shared risk factors for both prostate cancer and CVD stress the advantages of a unified approach to detection and management [10]. Incorporating CACS in this context holds promise for more precise risk stratification. It pulls existing imaging without extra scans, reducing patient burden while providing actionable data that can inform personalized cardiovascular prevention strategies. Early identification of high CACS could also spur lifestyle changes, such as weight management and structured exercise, which have shown effectiveness in lessening cardiometabolic risk factors [11].Nonetheless, challenges remain. First, applying CACS universally may prompt concerns about overdiagnosis and over-testing. Classifying certain patients as high-risk could inadvertently lead to anxiety or more aggressive interventions than needed, raising the potential for overtreatment. Second, the use of non-gated scans raises questions about variability in measurement accuracy when compared to standard cardiac gating methods. Third, the correlation between CACS and other forms of atherosclerosis, such as peripheral or cerebrovascular disease, is not always direct, so clinical decisions should not rely on CACS alone.There are also operational considerations. Radiologists and oncologists need consistent training on reading and interpreting CACS from these scans, and healthcare systems may need updated software and protocols to standardize data extraction and reporting. In settings with constrained resources, expanding CACS assessments may compete with other pressing healthcare demands [12]. Moreover, the lack of diversity in some study populations, including minimal representation of non-Caucasian groups, calls for validation in broader demographic settings.Finally, the interplay of novel hormonal therapies with cardiovascular risk factors remains complex. Some patients on ADT might see greater benefit from intensified cardioprotective measures than others, and further investigation is needed to clarify how CACS might aid in tailoring ADT choices. Overall, while integrating CACS could improve cardiovascular outcomes, the strategy must be balanced against the risk of unnecessary interventions and the practical realities of changing clinical workflows.Standardizing the use of CACS in prostate cancer management will require updated clinical guidelines. These should outline clear thresholds for risk-based interventions and emphasize integrated care among oncologists, cardiologists, and primary providers. Such guidelines could also address uniform reporting and interpretation of CACS to reduce variability across institutions. Patient engagement remains essential: clear explanations of cardiovascular risks and the advantages of preventive strategies, including statins and lifestyle modifications, can encourage adherence. Future research might examine how emerging technologies, such as advanced CT protocols or automated scoring software, refine CACS accuracy and feasibility in broader clinical settings. As more evidence accumulates, larger multicenter trials will help validate these approaches in diverse populations, ensuring that policy recommendations are robust and widely generalizable.The prognostic value of CACS for prostate cancer patients provides a practical tool for identifying those at heightened cardiovascular risk. Addressing the underuse of preventive measures such as statins can substantially reduce morbidity and mortality, stressing the importance of systematic, cross-specialty care. Moving forward, integrating CACS into routine workflows – together with closer coordination between oncology and cardiology teams – can improve patient outcomes. This alignment allows care plans to reflect both cancer status and cardiovascular vulnerability, optimizing long-term quality of life for a population living with, and beyond, prostate cancer.The authors have no conflicts of interest to declare.This study was not supported by any sponsor or funder.Kasper Emil Rosenbech: writing – original draft, writing – review and editing. Alaa Saeid and Manyoo Agarwal: writing – review and editing. Stephan Peronard Mayntz: conceptualization, writing – original draft, and writing – review and editing.