Position statement: Echo surveillance for childhood, teenage and young adult cancer survivors

Published 11/05/2026

Introduction

Childhood, teenage and young adult (CTAYA) cancer survivors treated with anthracyclines and/or radiotherapy (RT) are at increased risk of developing heart failure (HF) in the future “late effects” setting¹.

This risk depends on the amount of anthracycline exposure, whether concomitant radiation was given and the dose as well as field of the RT. An exposure to 250mg/m2 of doxorubicin or its equivalent anthracycline dose increases the risk of developing HF three times compared to unexposed survivors^2,3. If the exposure is >250mg/m2, the risk of developing HF increases nine times. The risk of death compared to non-cancer affected siblings is seven times more⁴.

For each 10 Gray (Gy) increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, there is a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease⁵.

A number of organisations have previously tried to codify these risks looking at the available literature for guidance⁶. The International Guidelines Harmonization Group (IGHG) defines risk into 3 groups with recommended surveillance screening as mentioned in table 1.

Risk group	Anthracycline mg/m2	Chest radiotherapy (Gray)	Anthracycline(mg/m2) + chest radiotherapy (Gray)	Screening	Interval
High	≥250	≥ 30	≥100 and ≥15	Yes	2 years
Moderate	100-250	15-<30	N/A	Maybe	5 years
Low	>0-<100	>0-<15	N/A	No	No screening

Table 1. International Guidelines Harmonization Group risk stratification and surveillance screening recommendations

The recommendations for duration, type and frequency of screening for late effect cardiotoxicity has evolved with the emergence of new data. Given the indefinite duration of some late effects’ screening, a particular emphasis has been placed on trying to establish cost-effectiveness of such programmes.

Ehrhardt and colleagues examined the cost-effectiveness of the International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) 2015 late effects guidelines^7,8. They estimated long term effects and economic impacts of screening in the Childhood Cancer Survivor Study (CCSS) and the St Jude Lifetime Cohort based on a derived microsimulation model of the clinical course of heart failure (HF). Routine screening was postulated to reduce the risk of lifetime HF by 4-11% depending upon frequency. Screening every 2, 5, and 10 years was cost-effective for high-risk survivors, and every 5 and 10 years for moderate-risk survivors. However, screening for low-risk survivors did not meet their a-priori definition of an incremental cost effectiveness ratio (ICER) of <$100,000 per Quality adjusted life year (QALY) gained. In contrast, ICERs were estimated at $175,000 per QALY gained for all strategies for survivors felt to be low risk (around 40% of all survivors fall in the low-risk category).

This joint BSE-CCLG-BCOS statement reviews the recent systematic review and updated recommendations from the IGHG⁹. The major recommendations offer guidance for frequency of surveillance for high-risk patients and the removal of surveillance for low-risk patients. The main evidence-base for these changes is referenced in the cost-effectiveness study by Ehrhardt and colleagues which was published in 2020⁸.

What are the changes between 2015 and 2023 guidance?

In the 2023 guidance, 2- or 3-dimensional (2D/3D) echocardiography to assess left ventricular ejection fraction (LVEF) is now suggested as the primary surveillance modality for the development of HF. Radionuclide imaging assessment of cardiac function is now no-longer recommended.

High-risk patients

Ehrhardt and colleagues found that screening high-risk survivors at 1-, 2-, 5-, and 10-year intervals averted 1 case of HF every 1,012, 667, 445, and 383 screening echocardiograms, respectively. For high-risk survivors, the ICERs for 10-year ($34,604 per QALY gained), 5-year ($37,703 per QALY gained), and 2-year ($77,877 per QALY gained) interval strategies were all, $100,000 per QALY gained, with the 2-year strategy yielding the greatest gain in QALYs. In their simulation, screening every 2y produced the optimal balance of risk of detection and cost.

High risk patients included those who have received >= 250mg/m2 of doxorubicin (or anthracycline equivalent), those who have received >=30Gy RT to the chest (was >=35Gy in the 2015 guidelines) and those that received a combination of >=100mg/m2 anthracycline and >=15Gy RT.

The 2023 guidelines recommend screening within 2y of end of cancer treatment and to take place every 2y (compared to 5 yearly intervals in the 2015 document). Lifelong screening is recommended.

Moderate-risk patients

In moderate-risk survivors, ICERs were $100,000 for screening every 10 years ($79,312 per QALY gained) and 5 years ($94,575 per QALY gained), with the probability that each strategy was preferred was only 0.14 and 0.35, respectively.

Moderate risk is defined as previous exposure to >=100-250 mg/m2 of doxorubicin (or anthracycline equivalent) and/or exposure to >=15-30Gy of chest-directed RT (was >=15-35Gy in the 2015 guideline).

There is no change between the 2015 and 2023 guidelines in terms of starting screening within 2y of end of treatment and continuing every 5 years indefinitely.

Low-risk patients

For low-risk patients, any type of surveillance strategy was found to be cost-ineffective with ICERs of $175,000 per QALY gained for all strategies. The probability that no screening was preferred was 0.70.

The new IGHG 2023 statement therefore suggests that unlike before, no screening is recommended for CTAYA cancer survivors treated with low doses of anthracycline (<100mg/m2 of doxorubicin or equivalent). Similarly, surveillance for the development of heart failure is now no longer recommended for CTAYA survivors exposed to low doses (<15Gy) of RT directed to the chest.

The changes in surveillance are summarized in table 2.

2015 guidelines	2023 guidelines
High-risk
Cardiomyopathy surveillance is recommended for survivors of CTAYA cancer at High risk to begin no later than 2 years after completion of cardiotoxic treatment, to be repeated at 5 years and then continue 5 yearly thereafter	Cardiomyopathy surveillance is recommended for survivors of CTAYA cancer at High risk to begin no later than 2 years after completion of cardiotoxic treatment, to be repeated at 2 years and then continue 2 yearly thereafter
Lifelong cardiomyopathy surveillance might be reasonable for survivors of CTAYA cancer at high risk	Lifelong cardiomyopathy surveillance is reasonable for survivors of CTAYA cancer at high risk
Cardiology consultation might be reasonable for survivors of CTAYA cancer at high risk who plan to participate in high intensity exercise to define limits and precautions.	Cardiology consultation is reasonable for survivors of CTAYA cancer at high risk who plan to participate in high intensity exercise to define limits and precautions.
Moderate-risk
Cardiomyopathy surveillance is reasonable for survivors of CTAYA cancer at moderate risk to begin no later than 2 years after completion of cardiotoxic treatment, to be repeated at 5 years and then continue 5 yearly thereafter.	No change
Lifelong cardiomyopathy surveillance might be reasonable for survivors of CTAYA cancer at moderate risk	Lifelong cardiomyopathy surveillance is reasonable for survivors of CTAYA cancer at moderate risk
Low-risk
Cardiomyopathy surveillance is reasonable for survivors of CTAYA cancer at Low risk to begin no later than 2 years after completion of cardiotoxic treatment, to be repeated at 5 years and then continue 5 yearly thereafter.	Cardiomyopathy surveillance is not recommended for survivors of CTAYA cancer at low risk

Table 2. Summary of surveillance changes between the 2015 and 2023 ICHG (International Late Effects of Childhood Cancer Guideline Harmonization Group) guidelines (CTAYA - Childhood, teenage and young adult)

BSE-CCLG-BCOS recommendations

The changes in the 2023 IGHG guideline imply more screening for high-risk survivors, same level of screening for medium risk survivors and no screening for low-risk survivors. Overall, it was felt that it was cost effective to screen for high and medium risk survivors but not for low-risk survivors. The health economic modelling was based on US data and cohorts. This may not translate directly into the UK healthcare system. Additionally local variations in accessibility to echocardiography and late effects services will need to be factored in if the recommendations are applied.

Ideally, a UK based health economic analysis within the context of NHS practice would be desirable. In the absence of this, consideration should be given to auditing UK practice if the 2023 IGHG recommendations are widely adopted.

Consideration may need to be given to new late effect pathway models e.g. physiologist delivered late effects echocardiographic screening clinics along the lines of physiologist delivered valve surveillance clinics.

We propose the following long-term monitoring approach in the UK (Table 3).

Level of risk	Definition of level of risk	Screening recommendation
High-risk	Anthracyclines ≥ 250 mg/m2 or chest-directed radiotherapy ≥ 30 Gy, or a combination of anthracyclines ≥100 mg/m² and chest-directed radiotherapy ≥15 Gy) *	Full study within 2 years of completion of treatment with targeted study every 2 years thereafter. If chest-directed radiotherapy received, full study recommended on each occasion.
Moderate-risk	Anthracyclines 100–249 mg/m² or chest-directed radiotherapy 15–29 Gy*, no combined treatment	Full study within 2 years of completion of treatment with targeted study every 5 years thereafter. If chest-directed radiotherapy received, full study recommended on each occasion.
Low risk	Anthracyclines <100 mg/m² and chest-directed radiotherapy <15 Gy*	Routine surveillance not recommended.

Table 3 Proposed approach for long term monitoring in the UK. (Gy – Gray)

* The dose to the heart in modern RT techniques will be lower than previous less conformal techniques if it's not in the target volume. Nowadays most RT dosimetry will include the mean heart dose, if relevant.

Where mean heart dose is available to consider using these parameters:

High-risk-2 yearly echoes = Mean heart dose (MHD) >15Gy or MHD 5-15Gy and >100mg anthracycline

Moderate-risk-5 yearly echoes= MHD 5-15Gy alone or 100-250mg anthracycline⁸

Based on these changes, we recommend a comprehensive full study including the BSE minimum transthoracic dataset with additional cardio-oncology measurements for the first late effects’ echocardiogram (similar to the baseline echocardiogram in the BSE and BCOS guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab0¹⁰ (Table 4).

View (Modality)	Measurement	Explanatory Note	Image
	Vital signs	Blood pressure, heart rate and rhythm
Apical 3D	3D volumes and LVEF	ECG signal with clear R-wave. Adjust scanner settings to ensure optimal resolution. Ensure ROI is within the 3D volume sector. Maximize the frame rate, adjusting number of subvolumes according to patient breath-holding capability as needed. Acquire images with the probe maintained in a steady position and at end-expiration. Before accepting acquisition, review volume and 9-slice view to ensure no stitch artifacts.
A4C/A3C/A2C GLS	GLS measurement	Optimal ECG signal with minimal heart rate variability should be present across 3 cardiac cycles. Heart rate variability will limit the calculation of GLS values, which can be problematic in patients with atrial fibrillation. High-quality image acquisition, maintaining a frame rate of 40 to 90 frames/s at a normal heart rate, is key.
		Clear endocardial and epicardial definition is required to ensure adequate segmental tracking throughout the cardiac cycle. Markers are placed in each of the respective basal and apical regions, using automated tracking where possible to maintain reproducible results. Automated tracking should also be combined with a visual assessment of tracking in each view across the whole ROI, including the endocardial and epicardial border. If more than 2 segments in any 1 view are not adequately tracked, the calculation of GLS should be avoided.
3D = 3-dimensional; A2C = apical 2 chamber; A3C = apical 3 chamber; A4C = apical 4 chamber; BSE = British Society of Echocardiography; ECG = electrocardiogram; GLS = global longitudinal strain; LVEF = left ventricular ejection fraction; ROI = region of interest.

Table 4. Minimum Requirements for Baseline Assessment for Patients Receiving Anthracyclines/Trastuzumab¹⁰ (in Addition to the Full BSE Minimum Dataset)¹¹

Subsequent surveillance echocardiography should be performed as targeted studies as described in the BSE and BCOS guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab (Table 5). However, in patients who have received radiotherapy with the heart in the radiotherapy field, a full comprehensive echocardiogram is recommended on each occasion to allow full valvular assessment.