Weekly Journal Scan: a novel risk-prediction tool for patients with acute coronary syndrome and cancer: the ONCO-ACS score

This comment refers to ‘Prediction of mortality, bleeding, and ischaemic events in patients with cancer and acute coronary syndrome: a model development and validation study’ which was published in The Lancet, https://doi.org/10.1016/S0140-6736(25)02020-3. The management of ACS in patients with cancer remains one of the most challenging scenarios in contemporary CV medicine.6 Advances in modern oncology have substantially improved cancer survival, reshaping the long-term risk profile of this population. Malignancy promotes a persistent proinflammatory and prothrombotic milieu, characterized by endothelial dysfunction, platelet activation, coagulation cascade activation, and cytokine-driven plaque instability.6,7 Furthermore, several anticancer therapies—including platinum-based agents, fluoropyrimidines, radiation therapy, and targeted or immune-based treatments—can accelerate atherosclerosis, induce coronary vasospasm, and increase the risk of plaque instability.6,8 These mechanisms operate on a background of shared traditional CV risk factors such as age, smoking, diabetes, and obesity. On the other hand, cancer-related cachexia, anaemia, renal dysfunction, thrombocytopenia, and frailty amplify both ischaemic and bleeding susceptibility.6–8 The result is a uniquely complex phenotype in which mortality, recurrent MI or stroke, and major bleeding frequently coexist as competing risks. Despite this vulnerability, patients with cancer have been underrepresented in randomized ACS trials, and have largely been excluded from the derivation of conventional ACS risk scores,2–4 that do not account for cancer-related biology, competing mortality, or treatment-specific ischaemic or bleeding risk.