Advancing cancer therapeutics: new perspectives on mechanisms, regulatory and policy challenges, and innovative multi-modality strategies for the early detection of cardiotoxicity

Abstract Recent advances in cancer therapeutics, particularly targeted agents and tissue agnostic immunotherapies, have transformed care while introducing new challenges in cardiovascular safety. Although clinical guidelines have evolved, regulatory processes critical to ensuring safe innovation remain under-leveraged and often disconnected from real-world implementation. This gap is especially concerning amid federal downsizing, which has led to significant staff reductions at the United States Food and Drug Administration (FDA) and other health agencies. To meet growing needs in patient safety and therapeutic oversight, a new paradigm is emerging-one that is collaborative, adaptive, and inclusive of all stakeholders. Drug manufacturers, oncologists, cardiologists, clinical trialists, regulators, and technology developers must integrate around shared goals. Cardiovascular endpoints should be integrated into pre–new drug application (NDA) studies, with trial designs that include at-risk populations and robust cardiac monitoring. Early detection tools and mitigation strategies should be co-developed when feasible alongside therapeutics and considered part of the approval process. Graphical abstract Integrated framework for drug-associated cardiotoxicity across the therapeutic lifecycle. The illustration highlights three essential domains: (1) Drug development, including predictive modeling, preclinical assessment, and structured clinical trials; (2) Patient care, incorporating surveillance and management strategies to mitigate cardiotoxicity risk; and (3) Regulatory activity, emphasizing safety evaluation and guideline development. This framework reflects the multidimensional process required to detect, manage, and prevent cardiotoxicity associated with cancer therapeutics.