Late cardiac toxicity in childhood cancer survivors is most commonly caused by prior administration of anthracycline (e.g., doxorubicin and daunorubicin). These drugs are associated with the late development of a cardiomyopathy that can result in congestive heart failure and arrhythmias. This complication can appear insidiously, without prior symptoms, and at any time during the post-cancer treatment period (Steinherz et al. 1991; Steinherz et al. 1995). Risk factors include cumulative anthracycline dose >300 mg/m2, age younger than 5 years at treatment, female gender, exposure to mediastinal irradiation, TBI, and combined administration of cyclophos-phamide (Lipshultz et al. 1991; Steinherz et al. 1991; Steinherz et al. 1995; Lipshultz et al. 1995; Gupta et al. 2003). In one study done at MSKCC among survivors of leukemia and solid tumors, at a median of 7 years after completion of anthracycline therapy (median dose, 450 mg/m2), the incidence of abnormal cardiac function on an echocardiogram was 23 % (Steinherz et al. 1991). A recent study from the same group showed a decrease in cardiac function in 20 % of the patients who had received bolus anthracycline (median dose 385 mg/m2) compared with 11% of patients who had received it via infusion (median dose 345 mg/m2) at a mean of 7 years after the end of therapy; however, this difference was not statistically significant (Gupta et al. 2003).

Some conditions, such as isometric exercise, pregnancy, labor, and delivery, and viral infections have been reported to precipitate cardiac decompensation following therapy with anthracyclines (Lipshultz et al. 1995). Close follow-up and monitoring of cardiac function is essential for patients who received an-thracyclines with or without chest irradiation during their cancer treatment.

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