Associations of onset age of breast cancer with incident myocardial infarction and heart failure: a prospective cohort study

Reviewer #1 (Public Review):

Summary:

The authors sought to investigate the associations of age at breast cancer onset with the incidence of myocardial infarction (MI) and heart failure (HF). They employed a secondary data analysis of the UK Biobank. They used descriptive and inferential analysis including Cox proportional hazards models to investigate the associations. Propensity score matching was also used. They found that Among participants with breast cancer, younger onset age was significantly associated with elevated risks of MI (HR=1.36, 95%CI: 1.19 to 1.56, P<0.001) and HF (HR=1.31, 95% CI: 1.18 to 1.46, P<0.001). the reported similar findings after propensity matching.

Strengths:

The use of a large dataset is a strength of the study as the study is well-powered to detect differences. Reporting both the unmatched and the propensity-matched estimates was also important for statistical inference.

Weaknesses:

Despite the merits of the paper, readers may get confused as to whether authors are referring to "age at breast cancer onset" or "age at breast cancer diagnosis". I suppose the title refers to the latter, in which case it will be best to be consistent in using "age at breast cancer diagnosis" throughout the manuscripts. I would recommend a revision to the title to make it explicit that the authors are referring to, "age at breast cancer diagnosis".

Reviewer #2 (Public Review):

This is a well-presented large analysis from the UK Biobank of nearly 250,000 female adults. The authors examined the associations of breast cancer diagnosis with incident myocardial infarction and heart failure by different onset age groups. Based on results from a series of statistical analyses, the authors concluded that younger onset age of breast cancer was associated with myocardial infarction and heart failure, highlighting the necessity of careful monitoring of cardiovascular status in women diagnosed with breast cancer, especially those younger ones.

Comments to consider:

(1) It's thoughtful for the authors to have included and adjusted for menopausal status, breast cancer surgery, and hormone replacement therapy in their sensitivity analysis. It would be informative if the authors presented the number and percentages of menopause and cancer treatments.

(2) The analytical baseline used for follow-up should be pointed out in the methods section. It's confusing whether the analytic baseline was defined as the study baseline or the time at breast cancer diagnosis.

(3) Did the older onset age group have a longer follow-up duration? Could the authors provide information on the length of follow-up by age of onset in Supplementary Table S4? It would give the readers more information regarding different age groups.