Version May 2024
| Guideline questions |
| This clinical practice guideline addresses the following five overarching clinical questions: Which patients with cancer are at increased risk for developing cardiac dysfunction? Which preventative strategies minimize risk before initiation of therapy? What strategies minimize risk during potentially cardiotoxic therapy? What are the preferred surveillance and monitoring approaches during treatment in patients at risk for cardiac dysfunction? What are the preferred surveillance and monitoring approaches after treatment in patients at risk for cardiac dysfunction? |
| Target population |
| The target population consists of adults with cancer for whom cardiotoxic anticancer therapies are being considered. |
| Target audience |
| This clinical practice guideline is targeted to oncologists, cardiologists, primary care physicians, specialists, practice providers, and any other relevant member of a comprehensive multidisciplinary cancer care team, as well as patients and their caregivers. |
| Methods |
| An expert panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature, with a focus on five overarching clinical questions. |
| 1. Which patients with cancer are at increased risk for developing cardiac dysfunction? |
Recommendation 1.1. It is recommended that patients with cancer who meet any of the following criteria should be considered at increased risk for developing cardiac dysfunction.
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Recommendation 1.2. No recommendation can be made on the risk of cardiac dysfunction in patients with cancer with any of the following treatment exposures:
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| 2. Which preventative strategies minimize risk before initiation of therapy? |
| Recommendation 2.1. Avoid or minimize the use of potentially cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes. (Consensus-based; benefits outweigh harms; strength of recommendation: strong.) |
| Recommendation 2.2. Clinicians should perform a comprehensive assessment in patients with cancer that includes a history and physical examination, screening for cardiovascular disease risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking), and an echocardiogram before initiation of potentially cardiotoxic therapies. (Evidence- and consensus-based; benefits outweigh harms; evidence quality: high; strength of recommendation: strong.) |
| 3. Which preventive strategies are effective in minimizing risk during the administration of potentially cardiotoxic cancer therapy? |
| Recommendation 3.1. Clinicians should screen for and actively manage modifiable cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, obesity) in all patients receiving potentially cardiotoxic treatments. (Informal consensus and evidence-based; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: moderate.) |
| Recommendation 3.2. Clinicians may incorporate a number of strategies, including use of the cardioprotectant dexrazoxane, continuous infusion, or liposomal formulation of doxorubicin, for prevention of cardiotoxicity in patients planning to receive high-dose anthracyclines (eg, doxorubicin ≥250 mg/m2, epirubicin ≥600 mg/m2). (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate.) |
Recommendation 3.3. For patients who require mediastinal RT that might impact cardiac function, clinicians should select lower radiation doses when clinically appropriate and use more precise or tailored radiation fields with exclusion of as much of the heart as possible. These goals can be accomplished through use of advanced techniques including the following:
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| 4. What are the preferred surveillance and monitoring approaches during treatment in patients at risk for cardiac dysfunction? |
| Recommendation 4.1. Clinicians should complete a careful history and physical examination in patients who are receiving potentially cardiotoxic treatments. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong.) |
Recommendation 4.2. In individuals with clinical signs or symptoms concerning for cardiac dysfunction during routine clinical assessment, the following strategy is recommended:
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| Recommendation 4.3. Routine surveillance imaging may be offered during treatment in asymptomatic patients considered to be at increased risk (Recommendation 1.1) of developing cardiac dysfunction. In these individuals, echocardiography is the surveillance imaging modality of choice that should be offered. Frequency of surveillance should be determined by health care providers based on clinical judgment and patient circumstances. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate.) |
| Recommendation 4.4. No recommendations can be made regarding continuation or discontinuation of cancer therapy in individuals with evidence of cardiac dysfunction. This decision, made by the oncologist, should be informed by close collaboration with a cardiologist, fully evaluating the clinical circumstances and considering the risks and benefits of continuation of therapy responsible for the cardiac dysfunction. (Informal consensus; benefits outweigh harms; evidence quality: insufficient.) |
| Recommendation 4.5. Clinicians may use routine echocardiographic surveillance in patients with metastatic breast cancer continuing to receiving trastuzumab indefinitely. The frequency of cardiac imaging for each patient should be determined by health care providers based on clinical judgment and patient circumstances. (Evidence-based and informal consensus; benefits outweigh harms; evidence quality: low; strength of recommendation: moderate.) |
| 5. What are the preferred surveillance and monitoring approaches after treatment in patients at risk for cardiac dysfunction? |
| Recommendation 5.1. Clinicians should complete a careful history and physical examination in survivors of cancer previously treated with potentially cardiotoxic therapies. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong.) |
Recommendation 5.1.1. In individuals with clinical signs or symptoms concerning for cardiac dysfunction, the following approaches should be offered as part of recommended care:
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| Recommendation 5.2. An echocardiogram may be performed between 6 and 12 months after completion of cancer-directed therapy in asymptomatic patients considered to be at increased risk (Recommendation 1.1) of cardiac dysfunction. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate.) |
| Recommendation 5.2.1. Cardiac MRI or MUGA may be offered for surveillance in asymptomatic individuals if an echocardiogram is not available or technically feasible (eg, poor image quality), with preference given to cardiac MRI. (Evidence-based; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate.) |
| Recommendation 5.3. Patients identified to have asymptomatic cardiac dysfunction during routine surveillance should be referred to a cardiologist or a health care provider with cardio-oncology expertise for further assessment and management. (Informal consensus; benefits outweigh harms; evidence quality: insufficient; strength of recommendation: strong.) |
| Recommendation 5.4. No recommendations can be made regarding the frequency and duration of surveillance in patients at increased risk (Recommendation 1.1) who are asymptomatic and have no evidence of cardiac dysfunction on their 6- to 12-month post-treatment echocardiogram. (Informal consensus; relative balance of benefits and harms; evidence quality: insufficient.) |
| Recommendation 5.5. Clinicians should regularly evaluate and manage cardiovascular risk factors such as smoking, hypertension, diabetes, dyslipidemia, and obesity in patients previously treated with cardiotoxic cancer therapies. A heart-healthy lifestyle, including the role of diet and exercise, should be discussed as part of long-term follow-up care. (Evidence-based and consensus; benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate.) |
| Additional resources |
| More information, including a data supplement with additional evidence tables, a methodology supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/cardiac-guideline. Patient information is available at www.cancer.net. |
| Qualifying statements |
| ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate. |
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