When to Refer a Survivor to Cardio-Oncology: A Primary-Care Threshold List
Concrete referral triggers for primary care: cumulative anthracycline dose, chest radiation fields, falling strain or ejection fraction, uncontrolled pressure on VEGF therapy, and new symptoms with a cardiotoxic history.
Most survivorship cardiac care belongs in primary care. The value of a cardio-oncology referral lies in the smaller set of situations where exposure history changes interpretation, and where a general cardiology view alone may under-read the risk.
Exposure-based triggers
High cumulative anthracycline exposure, chest radiation involving the heart, sequential anthracycline plus HER2-directed therapy, and prior mediastinal radiation in a young survivor all warrant a specialist view at least once, even when the patient is asymptomatic.
The purpose of that single visit is usually to set an individualised surveillance interval that primary care then runs, not to transfer care permanently.
Objective decline
A meaningful relative fall in global longitudinal strain with a preserved ejection fraction, any new fall in ejection fraction, a new regional wall motion abnormality, or new valvular disease in a radiation field should all prompt referral rather than a repeat study in a year.
Rising natriuretic peptides in a survivor with a cardiotoxic history and no clear alternative explanation carry the same weight.
Symptom-based triggers
New exertional breathlessness, orthopnoea, reduced exercise tolerance out of keeping with deconditioning, syncope, angina, or a new irregular pulse in a survivor with cardiotoxic exposure should be worked up promptly and referred where cardiac cause is plausible.
Chest pain in someone with prior chest radiation deserves a low threshold, because coronary disease can present atypically and earlier than an age-based risk score suggests.
What to put in the referral
Diagnosis and treatment dates, cumulative anthracycline dose in doxorubicin equivalents where known, radiation field and dose, HER2-directed or VEGF or checkpoint exposure, current ejection fraction and strain with dates, blood pressure and lipid control, and the specific question you want answered.
A referral that states the exposure detail gets a surveillance plan back. One that states only the symptom usually gets a generic assessment.
Frequently asked questions
- When should a cancer survivor be referred to cardio-oncology?
- On high cumulative anthracycline exposure or cardiac-field chest radiation, on objective decline such as falling strain or ejection fraction, on new cardiac symptoms with a cardiotoxic history, and on therapy-related problems such as refractory VEGF hypertension or suspected checkpoint myocarditis.
- What information should a cardio-oncology referral include?
- Diagnosis and treatment dates, cumulative anthracycline dose, radiation field and dose, other cardiotoxic exposures, current ejection fraction and strain with dates, risk-factor control, and a specific question.