Title:“Prevention and management of cardiovascular disease in adults with cancer: an International Cardio-Oncology Society (IC-OS) and Multinational Association of Supportive Care in Cancer (MASCC) clinical practice statement”
Authors: Susan Dent, Michelle B. Nadler, Anne Blaes, Ahamed Iqbal, Hannah Naa Gogwe Ayettey, Jose Alvarez-Cardona, Alexandre Chan, Eng-Siew Koh, Raul Cordoba Mascunano, Mridula George, Naa Adorkor Aryeetey, Erin J. Howden, Sase Kazuhiro, Nida Latif, Aya F. Ozaki, Cherith J. Semple, Tharshini Ramalingan, Neil M. Iyenger, Hope S. Rugo & Bogda Koczwara
Background
Cardiovascular disease is one of the most important competing causes of morbidity and mortality among cancer survivors. As cancer outcomes improve through earlier diagnosis and more effective therapies, long-term treatment-related complications have become increasingly important in survivorship care. Cardiovascular toxicity can occur directly through the effects of cancer therapy on the heart and vascular system, or indirectly through worsening of cardiovascular risk factors such as hypertension, diabetes, dyslipidemia, obesity, smoking, and physical inactivity.
The IC-OS/MASCC statement addresses a practical gap in cardio-oncology: many existing guidelines focus on cardiologists or cardio-oncology specialists, while cancer care providers often need concise guidance that can be applied during routine oncology visits. The statement emphasizes that cardiovascular care should not be separate from cancer care, but integrated into treatment planning, toxicity monitoring, and survivorship follow-up.
Methods
This clinical practice statement was developed through collaboration between members of the International Cardio-Oncology Society and the Multinational Association of Supportive Care in Cancer. The authors included experts in oncology, cardiology, pharmacy, survivorship, supportive care, and related disciplines from different international settings. The group identified key practice questions across the cancer care trajectory, including baseline cardiovascular risk assessment, management during treatment, prevention of cancer therapy-related cardiovascular toxicity, and post-treatment surveillance.
The recommendations were based on targeted literature reviews, with the 2022 European Society of Cardiology cardio-oncology guideline used as a major reference source. Additional literature was selected from the authors’ files and from evidence considered most relevant to the broad clinical scope of the statement. Final recommendations were agreed upon by consensus and presented as clinical practice statements focused on a minimum standard of cardiovascular care for adults with cancer.
Study Design
This was not a randomized trial or observational outcomes study. It was a peer-reviewed clinical practice statement designed to provide expert-opinion-based, practical recommendations for cancer care professionals. The target audience includes oncologists, nurses, pharmacists, nurse practitioners, allied health professionals, and other clinicians involved in cancer care.
The target population is adult cancer survivors from the time of cancer diagnosis. Adult survivors of pediatric cancers were not included. The statement focuses on realistic, globally applicable standards of care, recognizing that access to cardiology, cardio-oncology, primary care, imaging, and specialist services differs widely between regions.
Results
The IC-OS/MASCC group identified 5 overarching clinical practice recommendations for cancer care providers.
First, cancer care providers should perform cardiovascular risk assessment before starting cancer therapy. This includes identifying pre-existing cardiovascular disease, cardiovascular risk factors, and prior exposure to cardiotoxic therapies such as radiotherapy, anthracyclines, tyrosine kinase inhibitors, immune checkpoint inhibitors, and HER2-targeted agents.
Second, cancer care providers should identify and facilitate cardiovascular-related care during cancer therapy. This means recognizing when cardiovascular risk factors or symptoms require management by primary care, cardiology, cardio-oncology, internal medicine, pharmacy, or allied health services.
Third, measures should be taken before and during treatment to reduce the risk of cancer therapy-related cardiovascular toxicity. These include lifestyle counseling, management of comorbid cardiovascular disease, control of modifiable risk factors, careful selection of cancer therapy when equally effective alternatives are available, and reduction of exposure to cardiotoxic systemic therapy or radiation when clinically appropriate.
Fourth, cardiovascular status and risk factors should be monitored during therapy. Referral should be considered if risk factors become uncontrolled or if new signs or symptoms of cardiovascular disease develop.
Fifth, cardiovascular risk should be reassessed after completion of cancer therapy, or periodically in patients with advanced cancer receiving lifelong treatment. Cancer care providers should help develop a cardiovascular surveillance plan that continues beyond the active treatment period.
Cardiovascular Risk Assessment Before Treatment
The baseline assessment should include history, physical examination, and relevant investigations. The statement recommends assessing for pre-existing coronary artery disease, heart failure, arrhythmias, hypertension, diabetes, hyperlipidemia, smoking, obesity, and physical inactivity. Physical examination should include blood pressure, heart auscultation, and body mass index.
For patients undergoing systemic therapy, baseline laboratory assessment should include HbA1c and lipids, including LDL, HDL, and total cholesterol. An electrocardiogram is recommended for patients with pre-existing cardiovascular risk factors or cardiovascular disease, as well as for patients planned for therapies associated with arrhythmias or cardiovascular toxicity.
For patients receiving cancer drugs associated with left ventricular dysfunction, such as anthracyclines, baseline left ventricular function assessment is recommended. Transthoracic echocardiography with global longitudinal strain, when available, is considered the preferred approach. Cardiac MRI can be used when echocardiographic quality is poor, while MUGA scan can be considered when echocardiography is unavailable or not feasible.
The statement highlights the HFA-ICOS baseline cardiotoxicity risk assessment tool as the preferred cancer-specific tool. It categorizes patients into low risk below 10%, medium risk from 10% to 19%, and high risk at 20% or higher for cardiovascular complications. Patients at high or very high baseline risk should be considered for troponin and BNP testing and referred to cardio-oncology, cardiology, or another experienced cardiovascular provider before treatment when possible.
Risk Reduction During Cancer Therapy
The statement gives practical prevention measures that can be implemented before and during therapy. All patients should receive counseling on smoking cessation, exercise, weight management, and a heart-healthy diet. These interventions are relevant not only for cardiovascular health but also for cancer treatment tolerance and long-term outcomes.
For patients receiving cardiotoxic therapy, clinicians should use the lowest effective cumulative dose when possible. In high-risk patients, cardiotoxic agents should be avoided when equally effective alternatives exist. For patients receiving high-dose anthracyclines, such as cumulative doxorubicin doses above 250 mg/m² or equivalent, or those with pre-existing cardiomyopathy, liposomal anthracyclines or dexrazoxane may be considered when available.
For patients receiving thoracic radiation, including mediastinal, left breast, or chest wall radiation, the statement recommends optimizing total dose and fractionation. Techniques such as deep inspiration breath-hold can reduce mean heart dose. IMRT or proton therapy may be considered for patients at risk of cardiovascular toxicity when resources are available.
The statement also provides clear targets for cardiovascular risk factor management: HbA1c below 7%, blood pressure below 130/80 mmHg, and LDL below 70 mg/dL. The authors acknowledge that strict optimization can be difficult during active cancer therapy, so clinicians may need to balance immediate cancer treatment priorities with longer-term cardiovascular control.
Monitoring During Therapy
During active treatment, patients should be monitored for symptoms or signs of new or worsening cardiovascular disease. Reassessment is especially important at major transition points, such as initiation of a new therapy, treatment change, new symptoms, sustained changes in vital signs, or use of drugs that can worsen cardiovascular risk factors, including corticosteroids.
Referral to cardiology or cardio-oncology should be considered for new cardiovascular disease during treatment, decline in left ventricular function, new arrhythmias, poorly controlled hypertension or other risk factors, and concern for drug-drug interactions. Specific thresholds include LVEF below 53% and/or a global longitudinal strain drop greater than 15%.
Post-Treatment Surveillance
The statement emphasizes that cardiovascular toxicity may appear years after treatment. Some toxicities may develop 5 to 10 years after cancer therapy, while valvular disease may occur after more than 10 years. This makes survivorship planning essential.
All asymptomatic cancer survivors should receive education about potential long-term cardiovascular toxicities and should have a cardiovascular risk assessment after their last cancer treatment. Annual cardiovascular risk assessment is recommended, including review of cardiac symptoms and evaluation of risk factors such as diabetes, hypertension, and dyslipidemia.
An echocardiogram at 12 months post-therapy is recommended for patients treated with HER2-targeted therapy and for patients treated with a cumulative doxorubicin dose of 250 mg/m² or higher or equivalent. Patients at moderate risk may be considered for echocardiography every 5 years. High or very high-risk survivors should have echocardiography at years 1, 3, and 5 after completion of cardiotoxic therapy, followed by every 5 years thereafter.
Key Findings
The most clinically important message is that cardiovascular care begins before cancer therapy, not after toxicity appears. The statement positions cancer care providers as the first point of recognition for cardiovascular risk, because they see patients at diagnosis, treatment initiation, follow-up, and survivorship visits.
The document also makes cardio-oncology more practical for routine oncology practice. It does not ask every oncology team to deliver specialist cardiac care. Instead, it defines what cancer care providers should identify, what they should monitor, and when referral is needed.
Another important finding is the emphasis on global applicability. The recommendations recognize that many regions have limited access to cardio-oncology specialists, cardiac imaging, and primary care. In these settings, lifestyle counseling, risk factor identification, shared care, and community-based follow-up remain essential.
Key Takeaway Messages
Cancer care providers should assess cardiovascular risk before starting therapy, particularly when anthracyclines, HER2-targeted therapy, immune checkpoint inhibitors, tyrosine kinase inhibitors, or thoracic radiation are being considered.
The HFA-ICOS tool provides a practical framework for classifying cardiotoxicity risk as low, medium, or high, using thresholds of less than 10%, 10% to 19%, and 20% or higher.
Cardiovascular prevention should include lifestyle support, risk factor control, careful cancer therapy selection, and dose or radiation planning strategies when feasible.
Survivorship care must include long-term cardiovascular monitoring, because some treatment-related toxicities can appear years after cancer therapy ends.
The IC-OS/MASCC clinical practice statement provides a clear and practical framework for preventing and managing cardiovascular disease in adults with cancer. Its central message is that cardio-oncology is not only the responsibility of cardiologists. Cancer care providers have a direct role in identifying cardiovascular risk, reducing preventable toxicity, monitoring during treatment, and ensuring that survivors leave active therapy with a cardiovascular follow-up plan.
For oncology practice, the statement is especially useful because it translates broad cardio-oncology principles into actionable steps. Baseline risk assessment, targeted investigations, referral for high-risk patients, risk factor targets, therapy-specific monitoring, and long-term surveillance can all be built into routine cancer care. As more patients live longer after cancer diagnosis, cardiovascular health is becoming a core part of high-quality oncology care.
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