Surveillance during follow-up – Patients at increased risk of cardiac dysfunction
In asymptomatic patients considered to be at increased risk of cardiac dysfunction, perform cardiac imaging (preferably an echocardiogram, or a cardiac MRI or a gated heart pool scan) between 6-12 months and at 24 months after completion of cancer-directed therapy.
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 of cardiac dysfunction. Cardiac MRI or MUGA may be offered for surveillance in asymptomatic individuals if an echocardiogram is not available or technically feasible (e.g. poor image quality), with preference given to cardiac MRI). (Evidence based; benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: moderate)
Moderate
For asymptomatic patients who have been treated with cardiotoxic agents and who have normal cardiac function, periodic screening for the development of new asymptomatic left ventricular dysfunction with cardiac biomarkers and potentially cardiac imaging should be considered at 6-12 months, at 2 years post-treatment, and possibly periodically thereafter (Level of evidence – III)
Strong or moderate evidence for efficacy but with a limited clinical benefit, generally recommended
There is moderate confidence that the recommendation reflects best practice. This is based on (1) good evidence for a true net effect (eg, benefits exceed harms); (2) consistent results, with minor and/or few exceptions; (3) minor and/or few concerns about study quality; and/or (4) the extent of panelists’ agreement. Other compelling considerations (discussed in the guideline’s literature review and analyses) may also warrant a moderate recommendation
Strong evidence for efficacy with a substantial clinical benefit, strongly recommended
How this guidance was developed
This recommendation was adapted from the ASCO 2017 guideline on cardiac dysfunction in adult cancers (US). The source recommendation is based on a systematic review of the evidence conducted to February 2016 and was graded ‘moderate’ (using ASCO methods). ‘Gated heart pool scan’ is the relevant terminology used in Australia (rather than multi-gated acquisition (MUGA) scan). The inclusion of ‘and at 24 months’ reflects the more recent ESMO 2020guidelines on the management of cardiac disease throughout oncological treatment, in which the source recommendation, based on an evidence review to June 2018, was graded ‘B’ (using ESMO guidelines methodology adapted from the Infectious Diseases Society of America-United States Public Health Service Grading System).
The ESMO 2020 guidelines also recommend that ‘For patients with a history of mediastinal chest radiotherapy, evaluation for ischaemic heart disease, as well as valvular disease, is recommended, even if asymptomatic, starting at 5 years post-treatment and then at least every 3-5 years thereafter’ ('A').
Surveillance during follow-up – Patients at increased risk of cardiac dysfunction
In asymptomatic patients considered to be at increased risk of cardiac dysfunction, perform cardiac imaging (preferably an echocardiogram, or a cardiac MRI or a gated heart pool scan) between 6-12 months and at 24 months after completion of cancer-directed therapy.
This recommendation was adapted from the ASCO 2017 guideline on cardiac dysfunction in adult cancers (US). The source recommendation is based on a systematic review of the evidence conducted to February 2016 and was graded ‘moderate’ (using ASCO methods). ‘Gated heart pool scan’ is the relevant terminology used in Australia (rather than multi-gated acquisition (MUGA) scan). The inclusion of ‘and at 24 months’ reflects the more recent ESMO 2020guidelines on the management of cardiac disease throughout oncological treatment, in which the source recommendation, based on an evidence review to June 2018, was graded ‘B’ (using ESMO guidelines methodology adapted from the Infectious Diseases Society of America-United States Public Health Service Grading System).
The ESMO 2020 guidelines also recommend that ‘For patients with a history of mediastinal chest radiotherapy, evaluation for ischaemic heart disease, as well as valvular disease, is recommended, even if asymptomatic, starting at 5 years post-treatment and then at least every 3-5 years thereafter’ ('A').