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No increased risk of cancer death after endovascular aortic repair in a nationwide population-based cohort study
Fredrik Lilja1, Anders Wanhainen1,2, Kevin Mani1
1Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
Introduction:
The short-term benefits of endovascular aortic repair (EVAR) compared with open repair for the treatment of abdominal aortic aneurysm (AAA) patients are well established. However, concerns have been raised regarding a potential increased long-term cancer risk associated with EVAR, related to procedural and surveillance-related radiation exposure. The aim of this nationwide population-based cohort study was to evaluate whether EVAR is associated with an increased long-term cancer risk compared with open repair.
Methods:
All patients undergoing primary AAA repair for an intact AAA (ICD-10: I71.4) from January 2005 to February 2024 were identified from the Swedish National Patient Register. Previous and subsequent cancer diagnoses, as well as previous co-morbidities, for this cohort were recorded. Cause of death was retrieved from the Cause of Death Register. Inverse probability of treatment weighting (IPTW) was applied using propensity scores derived from baseline characteristics and co-morbidities. Weighted Cox regression models, with EVAR as the sole regressor, were then fitted for the event of a new cancer diagnosis and cancer related death.
Results:
Some 15 509 patients were identified (mean age of 73 years, 16.8% female, and 23.7% with a previous cancer diagnosis). After weighting, standardized mean differences for co-morbidities, age, sex, and recent hospital admissions were all within ±0.1. The median survival was 8.7 (95% c.i. 8.4 to 8.9) years for EVAR patients and 9.4 (95% c.i. 9.1 to 9.6) years for open repair patients. The median follow-up time was 4.9 (interquartile range (i.q.r.) 2.3 to 8.4) years for new cancer and 5.9 (i.q.r. 3.0 to 9.4) years for cancer-related death. Freedom from new cancer was lower in EVAR patients (HR 0.92 (95% c.i. 0.86 to 0.98)), whereas cancer-related survival was similar (HR 0.93 (95% c.i. 0.85 to 1.02)).
Conclusion:
EVAR was not associated with an increased risk of dying of cancer, but with an increased risk of being diagnosed with a new cancer. This should be interpreted carefully, as there is a clear risk of detection bias of otherwise unknown tumours due to routine imaging during EVAR surveillance.
