Avirup Guha, Director of Cardio-Oncology at Georgia Cancer Center, shared on X:
“RADICAL PC-2 gives the strongest randomized evidence yet for organizing cardio oncology around prostate cancer: assess CV risk in everyone – but don’t refer every man starting ADT to a specialist. New at ESC2026.
Pragmatic RCT: 2,487 men with recently diagnosed prostate cancer or first ADT exposure; 55 sites, 8 countries. Referral to cardiology/internal medicine added statin/BP treatment, smoking cessation, diet and exercise to usual care.
Median follow-up: 5.8 years. PHRI.ca Population Health Research Institute. We recruited around 180 of them.
The powered hierarchical outcome favored referral: Win ratio 1.60 (95% CI 1.42–1.81; P<.001). The hierarchy was CV death → MI → stroke → HF → total cholesterol >155 mg/dL (4 mmol/L) → SBP >130 mm Hg.
Important: A win ratio of 1.60 is not a 60% event reduction.
Cholesterol control generated 99.4% of net wins; BP −0.9%. Total cholesterol was 12 mg/dL lower; close-out statin use was 63% vs 40%. This was chiefly a risk-factor-control result.
The nonpowered co-primary clinical composite – CV death/MI/stroke/HF – was not reduced: sHR 1.08 (95% CI 0.79–1.49; P=.62). Only 171 patients (6.9%) had an event.
So: no demonstrated hard-event benefit, not proof of no benefit.
Uptake was pragmatic and imperfect: 90% vs 21% saw a specialist; close-out antihypertensive use was 56% vs 49%. Crossovers, nonadherence and fewer events than expected limited power for clinical-event differences.
Prespecified subgroup signals: total cholesterol >4 vs ≤4 mmol/L had win ratios 1.75 vs 1.21 (P-int=.016). Clinical-event estimates were more favorable with BP ≥130/80 or known HTN, and directionally with diabetes.
Caveat: exploratory, nonpowered and not multiplicity-adjusted. None of those higher-risk strata independently showed significant clinical-event reduction. These are hypotheses – and markers of room for risk-factor improvement – not proof.
Practice takeaway: assess BP, lipids, diabetes, smoking and lifestyle universally in prostate cancer care. Build treatment pathways; refer selectively for uncontrolled risk, known CVD/symptoms, diagnostic uncertainty or complexity.
Hope everyone in the room with Darryl Leong had a great time and congrats to the entire RADICAL PC group for the excellent trial and thanks to patients who helped us get insights to help the next generation!”
Title 1: Specialist Referral for Cardiovascular Risk in Patients With Prostate Cancer: A Randomized Clinical Trial
Authors: Darryl P. Leong, Celestia Higano, Cristina Cano Garcia, Vincent Fradet, D. Robert Siemens, Tamim Niazi, Bobby Shayegan, Avirup Guha, Filipe Cirne, Joseph B. Selvanayagam, Philippe D. Violette, Felipe H. Valle, Luke T. Lavallée, Emmanuelle Duceppe, Patrick Anderson, Denis Xavier, Jose Patricio Lopez-Lopez, Nicolas Villareal Trujillo, Ariel Galapo Kann, Rafaela K. Piccoli, Marina Mourtzakis, David Sarid, Srivatsa Narasimha, Patrick P.P.W. Luke, Ludhmila A. Hajjar, Himu Lukka, Laurence Klotz, Kumar Balasubramanian, Rajibul Mian, Steven Agapay, Sumathy Rangarajan, Sarah Karampatos, Kelvin K. H. Ng, Alvaro Avezum, P. J. Devereaux, Jehonathan H. Pinthus for the RADICAL PC Investigators
Title 2: Identifying Patients With Prostate Cancer Who Benefit Most From Routine Cardiovascular Specialist Referral
Authors: Cristina Cano Garcia, Jehonathan Pinthus, Alvaro Avezum, P.J. Devereaux, Laurence Klotz, Celestia Higano, Vincent Fradet, Joseph Selvanayagam, Avirup Guha, Ludhmila Hajjar, Jose Patricio Lopez-Lopez, Denis Xavier, Kelvin Ng, Sumathy Rangarajan, Sarah Karampatos, Steven Agapay, Rajibul Mian, Kumar Balasubramanian, Filipe Cirne, Melissa Huynh, Margot K. Davis, Robert J. Hamilton, Darin Gopaul, Som D. Mukherjee, Malik Farooqi, Alexander P. Benz, Rachel Richard, Chieh Yang Christopher Koo, Darryl P. Leong on behalf of the RADICAL PC Investigators
You can also read:
Chemotherapy in Prostate Cancer: Current Evidence and Clinical Applications
