Cardiac Side Effects: Reducing Risks, Pediatric Cancer- Part 3
Heart Health: Long-Term Follow-up Recommendations after Cancer Therapy
This is the last in a three-part series on heart health following pediatric cancer therapy. In the first article, we looked at the possible long-term cardiac side effects of treatments for childhood cancer. The second article discussed types of tests recommended as part of a long-term follow-up plan. For part three, we will cover the recommended long-term follow-up schedules. We will also touch on general strategies for reducing the risks of adverse cardiac side effects.
Survivorship Care Plan
Your child’s care team will guide you in navigating follow-up schedules by helping you create a personalized Survivorship Care Plan (SCP). The SCP is a document that includes the following information:
- Type, location, and grade of cancer treated
- Details of treatments received (type, dose, duration, location, response)
- Side effects to look out for
- Recommended follow-up tests and timelines
- Nutrition and lifestyle recommendations
- Contact information for providers involved in follow-up care.
Timelines For Follow-up
Your child will enter the phase known as survivorship at around two years after completion of cancer treatment. Follow-up after cancer therapy often involves frequent visits and tests during the early survivorship period. However, the frequency of these visits usually decreases over time.
The following screening schedule is intended for children treated with anthracycline chemotherapy and/or receiving radiation to the chest, abdomen, or spine. Your doctor may make slightly different recommendations based on your child’s individual case.
Physical Exam Schedule
At a minimum, children treated with therapies that carry risks for heart dysfunction should receive an annual physical exam. This exam should involve a special focus on cardiac signs and symptoms. The yearly physical will include a blood pressure check. Your child’s provider may order bloodwork to check cholesterol, blood sugar, and other basic metabolic functions.
EKG Schedule
A technician should perform an electrocardiogram (EKG) at the first visit. They may repeat the EKG on follow-up visits if the initial EKG is abnormal.
Echocardiogram Schedule
Depending on the chemo or radiation dosage, your child’s provider may request that an Echocardiogram (Echo) be performed. Current survivorship guidelines include the following frequency recommendations:
- For children who receive only low-dose Anthracycline chemo (<100 mg/m2): No follow-up Echo is recommended unless symptoms are noted.
- For children who receive only low-dose radiation (<15 Gy), no follow-up Echo is recommended unless symptoms are noted.
- For children who receive a moderate radiation dose (15 to < 30 Gy) with zero or low-dose Anthracycline chemo, an Echo is recommended every five years.
- For children who receive a moderate Anthracycline chemo dose (≥100 to <250 mg/m2) with zero or low-dose radiation, an Echo is recommended every five years.
- For children who receive both a moderate Anthracycline chemo dose and a moderate radiation dose, Echo is recommended every two years.
- For children who receive any high Anthracycline chemo dose (≥250 mg/m2) or any high radiation dose (≥30 Gy), Echo is recommended every two years.
Non-scheduled Testing
Some heart tests do not have specific follow-up schedules. Instead, a provider may request these tests if more information is needed.
If the results of the Echo are unclear, your child may need to have an MRI or CT scan. The doctor may request these scans if further details are required.
If initial testing or symptoms point to heart rhythm abnormalities, your doctor may order a heart monitor. For suspicion of Coronary Artery Disease, the doctor may order a stress test.
Other Important Considerations for Life After Cancer Treatment
Much of the health surveillance necessary after cancer treatment takes place in your child’s day-to-day life. The adults who see them in ordinary circumstances do most of this monitoring. Parents and guardians are often the first people to notice small changes that could signal health problems. Be on the lookout for signs of chest pain, shortness of breath, swelling, or excessive fatigue.
Some heart problems may present differently in children and adolescents than they do in adults. Consider investigating further if you notice nausea/vomiting, increased irritability, changes in mood or demeanor, or clammy skin.
Health Conditions and Lifestyle Factors
Certain underlying factors may further increase your child’s heart risk beyond what we would typically expect with cancer therapy.
Health conditions such as diabetes, obesity, high blood pressure, and high cholesterol put additional strain on the heart. Making healthy lifestyle choices can help to prevent or offset these background risk factors. These choices include following a nutritious diet, avoiding alcohol and tobacco, managing emotional stress, and exercising regularly. A healthy diet is low in sugar and fats. Dietitians are often part of your care team and can give you guidance on specialized diets.
Strenuous Exercise
We know that exercise is vital to health. However, intense physical exertion (such as that required for many varsity-type sports) can be dangerous to patients with heart problems. Your doctor can provide you with specific screening recommendations and limitations if your child plans to participate in strenuous activity.
Substance Use and Medications
In addition, anabolic steroids, stimulant drugs, and certain medications can increase the chances of heart damage and cardiac side effects. You should always discuss the use of these substances with your follow-up clinician before starting.
Future Pregnancy
Finally, female survivors who are considering becoming pregnant will require specific testing and follow-up before and during pregnancy. Pregnancy puts significant strain on the cardiovascular system. Thus, close monitoring and guidance by a knowledgeable provider during the childbearing years is crucial.
Some of these considerations may seem ages away for your child. Remember that survivorship guidelines account for the various developmental milestones your child may encounter across their entire lifespan.
Cardiac Side Effects – From Diagnosis to Long-Term Follow-Up
Pediatric cancer is a life-altering experience for both the patient and their loved ones. After undergoing treatment, a whole new survivorship journey begins with many ups and downs along the way. Fortunately, numerous tools, organizations, and individuals are available to help you navigate the path from diagnosis to long-term follow-up.
References
American Cancer Society. (2025, February 3). Helping Your Child Transition from Treatment to Survivorship. https://www.cancer.org/cancer/childhood-cancer/survivorship.html#:~:text=end%20of%20treatment.-,Survivorship%20care%20focuses%20on%20the%20long%2Dterm%20wellbeing%20of%20individuals,care%20of%20childhood%20cancer%20survivors.
Baylor College of Medicine. (2025). Welcome to the Passport for Care! Even more importantly, Welcome to Survivorship!. https://cancersurvivor.passportforcare.org/en/welcome-to-the-passport-for-care-even-more-importantly-welcome-to-survivorship/
Cancer Nation. (2025). Care Planning for Cancer Survivors. https://canceradvocacy.org/resources/care-planning-for-cancer-survivors/#toggle-id-1
Children’s Oncology Group. (2023, October). Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers (Version 6.0). https://survivorshipguidelines.org/pdf/2025/COG_LTFU_Guidelines_Only_v6.pdf
Children’s Oncology Group. (2023, October). Introduction to long-term follow-up after cancer treatment (Health Link, Version 6.0). https://www.survivorshipguidelines.org/pdf/2023/English%20Health%20Links%20V6%20Secured/22_Heart_Health_v6%20(secured).pdf
National Coalition for Cancer Survivorship. (2024). Cancer Survivorship Checklist. https://canceradvocacy.org/wp-content/uploads/Survivorship-Checklist-AYA-Finished-Treatment.pdf
