External validation of the systematic coronary risk evaluation 2 (SCORE2) and SCORE2-older persons in cancer patients

The 2022 European Society of Cardiology cardio-oncology guidelines recommend cardiovascular disease (CVD) risk stratification for cancer patients and suggest using SCORE2 and SCORE2-OP. However, these models have not been validated or specifically adapted for cancer populations. Our aim was to refine the SCORE2 and SCORE2-OP models to accurately predict 10-year fatal and non-fatal CVD risk in cancer patients.

We included 1622 patients from the HUNT3 study (2006-08) who were diagnosed with cancer within 4 years after their enrolment and followed until 2023 linked to national registries. The primary outcome was a composite of myocardial infarction (MI), stroke, or CVD mortality. Model performance was assessed using Harrel's C-statistic and calibration curves. Both models were recalibrated by applying a multiplicative adjustment factor based on expected-observed (E/O) ratios. The most prevalent cancers were gastrointestinal (23%), prostate (17%), and breast (14%). Mean age was 65.2 years, 52% were female. During a median follow-up of 8.8 years [inter-quartile range 1.9-12.6], 252 CVD events (39% MI, 36% stroke, 25% CVD deaths) and 708 non-CVD deaths occurred. SCORE2 initially underestimated CVD risk (E/O ratio for men and women: 0.91 and 0.63, respectively) but showed adequate agreement after recalibration. C-statistics for SCORE2 was 0.693 [95% confidence interval (CI) 0.643-0.743], and 0.730 (95% CI 0.676-0.784) after excluding those not surviving the first 2 years. For SCORE2-OP, the C-statistics were 0.586 (95% CI 0.529-0.643) and 0.648 (95% CI 0.577-0.720).

SCORE2 underestimated CVD risk in cancer patients. After recalibration, the model may serve as a valuable tool for risk stratification in cancer patients.