Dear Editor,
The expanding field of cardio-oncology has substantially improved cardiovascular care for patients with cancer, supported by an increasing body of evidence and the publication of international guidelines (1). Nevertheless, translating these recommendations into routine clinical practice remains challenging. Daily real-world experience continues to highlight a persistent gap between guideline-based strategies and feasible implementation across diverse healthcare settings (2, 3). One of the most critical challenges is the early identification of patients at risk for cancer therapy–related cardiovascular toxicity. Although contemporary guidance emphasizes comprehensive baseline cardiovascular assessment prior to initiating potentially cardiotoxic cancer therapy (1), real-world practice frequently reveals incomplete or delayed evaluations, particularly in patients without known cardiovascular disease or those managed outside specialized centers (2, 3). Limited access to advanced echocardiographic techniques — especially deformation imaging — and variability in biomarker availability complicate risk stratification and timely detection of subclinical dysfunction (3, 4). A closely related barrier is the lack of standardized, pragmatic surveillance pathways that can be consistently implemented. Even where strain imaging is recommended for detecting early myocardial changes, heterogeneous local protocols and workflow limitations lead to wide variation in monitoring frequency, modality selection, and thresholds for action (1, 4). Real-world surveys further suggest that echocardiography practice in oncology often falls short of standards proposed by dedicated recommendations, underscoring the need for structured pathways and dedicated cardio-oncology services (2). Preventive and cardioprotective strategies represent another area where evidence does not consistently translate into practice. Systematic evidence supports the potential benefit of cardioprotective pharmacotherapy to attenuate anthracycline-associated declines in left ventricular function (5), and contemporary network analyses continue to refine comparative effectiveness across drug classes (6). However, adoption remains inconsistent due to resource constraints, uncertainty regarding patient selection in heterogeneous populations, and limited integration of prevention protocols into oncology workflows (3, 5, 6). Interdisciplinary collaboration is a further cornerstone that remains difficult to operationalize. Optimal cardio-oncology care requires continuous coordination among cardiologists, oncologists, hematologists, and radiation oncologists; yet fragmented referral pathways, time constraints, and the absence of dedicated multidisciplinary clinics often result in delayed referrals and reactive — rather than preventive — cardiovascular management (3). In parallel, treatment decision-making frequently relies on clinical judgment beyond current guideline algorithms, reflecting persistent evidence gaps, selection bias in preventive trials, and underrepresentation of complex patients with multimorbidity in randomized studies (1, 7) . Emerging technologies may help address several of these implementation barriers, particularly in settings with limited expert imaging capacity. Deep learning–based automated echocardiographic evaluation has demonstrated feasibility for improving efficiency and reproducibility of functional measurements (8), and recent clinical calls to action emphasize the potential role of artificial intelligence for earlier detection and more scalable monitoring approaches in cardio-oncology (9). Yet, real-world uptake is constrained by infrastructure, validation across diverse vendors and populations, and integration into clinical governance and workflow (8, 9). Finally, long-term survivorship care introduces additional real-world complexities. As cancer survival improves, structured approaches such as cardio-oncology rehabilitation and exercise-based prevention are increasingly discussed, but implementation is often limited by resource availability, uncertain referral pathways, and variable evidence across cancer subgroups (10). Such challenges reinforce the need for pragmatic, resource-adapted strategies that can extend beyond tertiary centers and support continuity of care across the cancer continuum (3, 10). In conclusion, real-world cardio-oncology practice continues to expose the disconnect between guideline recommendations and everyday clinical realities. Bridging this gap will require simplified and pragmatic risk assessment tools, standardized surveillance pathways, strengthened interdisciplinary collaboration, and implementation-focused research that reflects real-world complexity (7). Broader adoption of validated enabling technologies may also support scalable monitoring and improve reproducibility where expertise or resources are limited (8, 9). Without these efforts, the benefits of guideline-based cardio-oncology care may remain aspirational rather than consistently achievable for many patients with cancer (1, 3).
