Table 1.

Suggested Temporary Modifications to Routine Imaging Recommendations in Patients Receiving Cancer Therapy During the COVID-19 Pandemic

Routine Practice Recommendations	Potential Modifications During COVID-19
Pretreatment: anthracyclines	Baseline imaging if:
Baseline imaging before treatment with potentially cardiotoxic therapies (4,10)	1. History of significant CVD (e.g., MI, cardiomyopathy, arrhythmia, moderate or greater valvular disease) 2. Signs and symptoms of cardiac dysfunction 3. 2 or more risk CV factors for CTRCD^∗ 4. High anthracycline dose (e.g., doxorubicin-equivalent ≥250 mg/m² )^†
Pretreatment: trastuzumab	Baseline imaging if:
Baseline imaging before treatment with potentially cardiotoxic therapies (4,10)	1. History of CVD (e.g., MI, cardiomyopathy, arrhythmia, moderate or greater valvular disease) 2. Signs and symptoms of cardiac dysfunction 3. Two or more risk CV factors for CTRCD^∗ 4. Exposure to anthracycline as part of current or previous treatment^‡
During treatment: anthracyclines
ASCO: Routine imaging surveillance may be considered in asymptomatic patients considered at increased risk of cardiac dysfunction with frequency determined by health care provider based on clinical judgment (4) ESMO: after each additional 100 mg/m² beyond 250 mg/m², as discussed elsewhere (10) Repeat imaging early upon diagnosis of CTRCD to guide re-initiation of cancer therapy or titrate cardiac medications	1. No routine screening in asymptomatic individuals during pandemic but return to institution-specific protocols post-pandemic 2. Consider in those with HF signs/symptoms, high doses of doxorubicin-equivalent (e.g. ≥400 mg/m²), or those reaching 250 mg/m² with prior CVD or multiple CV risk factors^∗ with a continued need for anthracycline treatment 3. Early repeated imaging upon diagnosis of CTRCD should be performed as per institutional practices
During treatment: trastuzumab
Variability in practice, FDA package insert recommends baseline imaging and every 3 months during duration of trastuzumab therapy Repeat imaging early upon diagnosis of CTRCD to guide re-initiation of cancer therapy or titration of cardiac medications (10)	1. No prior anthracycline or CVD risk factors,^∗ consider imaging at 6 and 12 months into trastuzumab therapy only^§ 2. Prior anthracycline exposure, CV risk factors,^∗ with prior normal LVEF, consider follow-up imaging at 3, 6, and 12 months into trastuzumab therapy 3. Continue every 3 months imaging if known CVD, HF signs or symptoms, or low normal or reduced LVEF on previous testing 4. Metastatic setting: First year: repeat imaging every 6 months. Beyond first year: defer any further imaging if asymptomatic and results of previous studies normal 5. In patients who develop CTRCD, repeat imaging to guide ongoing cancer therapy or titration of cardiac medications
Post-treatment: adult survivors of childhood and adolescent cancers
1. Imaging in childhood cancer survivors: no later than 2 yrs after completion of treatment, at 5 yrs after diagnosis, and every 5 yrs (14) 2. Imaging in adolescent and young adult cancer survivors: every 1–2 yrs in high-risk patients (15)	Avoid screening studies in all survivors until end of pandemic unless there are HF symptoms or a change in cardiovascular status
Post-treatment: adult cancer survivors
1. Imaging in high risk asymptomatic patients at 6–12 months post-treatment (4) and 2 yrs after treatment/periodically (10) 2. Imaging in symptomatic survivors (4)	Temporarily defer routine follow-up imaging in all patients unless there are HF symptoms or a change in cardiovascular status

ASCO = American Society of Clinical Oncology; COVID-19 = coronavirus disease-2019; CV = cardiovascular; CVD = cardiovascular disease; ESMO = European Society of Medical Oncology; FDA = U.S. Food and Drug Administration; HF = heart failure; MI = myocardial infarction.

^∗

Age ≥60 years, hypertension, diabetes, dyslipidemia, smoking, obesity.

^†

If the only risk factor is high anthracycline dose (e.g., doxorubicin-equivalent ≥250 mg/m²), it is reasonable to consider imaging only once the high anthracycline dose threshold is met or after completion of cancer therapy.

^‡

If imaging in the previous 6 months shows normal cardiac function (left ventricular ejection fraction [LVEF] ≥55%) and the absence of significant valvular disease, additional baseline testing can be deferred.

^§

Screening at 6 months should likely identify most patients with cancer therapy–related cardiac dysfunction (CTRCD) (7).