Echocardiogram Frequency After Chemotherapy
For patients who received anthracyclines and/or trastuzumab in the adjuvant setting, perform echocardiograms at baseline, 3,6, and 9 months during treatment, then at 12 and 18 months after starting treatment, with one final surveillance echo between 6-12 months after completion of therapy for high-risk patients. 1
During Active Treatment (Adjuvant Setting)
For anthracycline and/or trastuzumab therapy:
- Baseline echo before starting chemotherapy 1
- Every 3 months during treatment (at 3,6, and 9 months) 1
- At 12 and 18 months after treatment initiation 1
- Additional monitoring as clinically indicated if abnormalities develop 1
For trastuzumab specifically:
- Standard monitoring every 3 months during treatment 1
- Consider confirmatory assessment 3 weeks after any initial asymptomatic LVEF decrease 1
- For metastatic breast cancer patients continuing trastuzumab indefinitely, routine surveillance frequency should be determined by clinical judgment 1
For VEGF inhibitors (sunitinib, sorafenib, pazopanib):
- Baseline assessment required 1
- Early follow-up at 2-4 weeks after starting therapy if baseline risk is high 1
- Every 6 months thereafter until LVEF values stabilize 1
After Completion of Chemotherapy
For asymptomatic high-risk patients:
- One echocardiogram between 6-12 months after completion of therapy 1
- This timing is based on evidence that most treatment-associated cardiac dysfunction develops within the first year after completion 1
High-risk criteria include: 1
- Age ≥60 years (increased vigilance recommended) 1
- High cumulative anthracycline doses (doxorubicin >240 mg/m² or epirubicin >360 mg/m²) 1
- Combination of anthracyclines with trastuzumab 1
- Pre-existing cardiovascular risk factors 1
Long-Term Surveillance
For patients treated at young age or with high cumulative doses:
- Assessment at 4 and 10 years after anthracycline therapy for patients treated at <15 years of age 1
- Also applies to patients >15 years with cumulative doxorubicin >240 mg/m² or epirubicin >360 mg/m² 1
- Lifelong surveillance recommended for survivors exposed to high cumulative anthracycline doses and/or chest radiotherapy 1
For patients with normalized LVEF after cardiotoxicity:
- Continue cardiac surveillance with echocardiography at 6-month intervals for the first year after normalization 2
- For anthracycline-treated patients, long-term surveillance at 1 and 5 years after completion of cancer treatment 2
Metastatic Disease
For patients treated for metastatic disease:
- LVEF monitoring at baseline 1
- Infrequent monitoring thereafter in the absence of symptoms 1
- This differs significantly from the adjuvant setting due to different risk-benefit considerations 1
Important Caveats
No further routine surveillance if initial post-treatment echo is normal:
- Current guidelines cannot make specific recommendations regarding frequency and duration of continued surveillance in asymptomatic high-risk patients who have a normal 6-12 month post-treatment echocardiogram 1
- However, patients should undergo careful history and physical examination at regular intervals 1
When to perform additional imaging:
- Any clinical signs or symptoms concerning for cardiac dysfunction (chest pain, shortness of breath, ankle swelling, decreased exercise tolerance, palpitations, lightheadedness) warrant immediate echocardiogram 1
- If LVEF declines ≥10% from baseline or drops below 50%, reassess after 3 weeks 1
Alternative imaging modalities:
- Cardiac MRI or MUGA may be used if echocardiogram is not available or technically feasible (poor image quality), with preference for cardiac MRI 1
- Three-dimensional echocardiography preferred over two-dimensional when available 1
Biomarker monitoring: