Top Things to Know: Cardiovascular Toxicity in Patients Treated for Childhood Cancer
Published: March 19, 2025
Prepared by Barbara Entl, MD; Science and Medicine Advisor; American Heart Association
- Pediatric cardio-oncology is a multidisciplinary field focused on cardiac complications during and after cancer treatment. Although children represent about 5% of new cancer diagnoses annually, their five-year survival rate exceeds 85%, resulting in nearly 500,000 survivors.
- Despite advancements, short- and long-term side effects of chemotherapy continue to pose risks for cardiovascular disease (CVD), including ventricular dysfunction, coronary artery disease, and arrhythmias, presenting a significant challenge for young patients.
- This scientific statement reviews current data on pediatric patients and survivors of pediatric cancer, offering updates on established cardiotoxic therapies, care transitions after treatment, the impact of cardiovascular (CV) risk factors, and approaches to exercise and cardiac rehabilitation.
- Anthracyclines, a class of drugs used for hematological and solid malignancies, can cause cardiotoxicity, primarily manifesting as cardiomyopathy and left ventricular (LV) dysfunction, along with arrhythmias and pericarditis. Further decreases in LV mass, wall thickness, and cardiac function may occur during survivorship, potentially leading to heart failure.
- Radiotherapy, platinum agents, steroids, and L-asparaginase can lead to various endocrine abnormalities, such as pancreatitis, insulin resistance, reduced insulin production, growth hormone deficiency, and hypogonadism, contributing to dyslipidemia and metabolic syndrome.
- Chest-directed radiotherapy (RT) is a recognized risk factor for late CVD in childhood cancer survivors. Recent data show that calculating mean RT doses to cardiac substructures improves the prediction of late CVD risk, indicating that no RT dose is entirely safe regarding late cardiac complications.
- Adult survivors of childhood cancer face increased mortality risk from major cardiovascular events—such as heart failure, stroke, and coronary artery disease—making early recognition of CVD crucial.
- While two-dimensional echocardiography remains the preferred imaging modality, left ventricular ejection fraction (LVEF) in adolescents and young adults may be more effectively assessed using 3D echocardiography. Global longitudinal strain serves as an additional measure alongside LVEF.
- Successful transitioning of care from pediatric to adult healthcare settings is crucial for the long-term health of survivors, many of whom face one or more chronic health conditions, including cardiovascular, reproductive, and endocrine disorders. A significant portion experiences severe or life-threatening issues, with these risks tending to increase with age.
- Integrating findings from genomic studies could further refine CVD risk assessment prior to initiating cardiotoxic therapy. Such insights into the pathogenesis of chemotherapy-associated cardiotoxicity would enable more precise risk determination, development of novel blood biomarkers, and identification of new therapeutic targets.
Citation
Ryan TD, Bates JE, Kinahan KE, Leger KJ, Mulrooney DA, Narayan HK, Ness K, Okwuosa TM, Rainusso NC, Steinberger J, Armenian SH; on behalf of the Pediatric Heart Failure & Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. Cardiovascular toxicity in patients treated for childhood cancer: a scientific statement from the American Heart Association. Circulation. Published online March 19, 2025. doi: 10.1161/CIR.0000000000001308