Cardio-oncology from the consulting side: diagnostic thresholds, surveillance and treatment responsibility among cardiologists and internists in a German multicentre survey

Background Cancer therapy-related cardiovascular toxicity (CTR-CVT) is a leading non-cancer cause of morbidity and mortality. The 2022 ESC Guidelines define a multidisciplinary pathway in which baseline cardiovascular risk assessment is led by the treating oncology or haematology team, with cardiological involvement guided by the resulting risk; how this is put into practice in hospitals is poorly characterised. Previous surveys have described the treating specialties; we examined the receiving cardiologists and internists. Methods Cross-sectional online survey of physicians in cardiology, internal medicine, gynaecology and oncology at 1,435 German hospital departments (February–October 2025). This pre-specified analysis addressed cardiological involvement in the pathway and in risk stratification, left-ventricular ejection fraction (LVEF)-decline thresholds, strain use and biomarker testing in a standardised high-risk scenario (a patient with pre-existing heart failure receiving anthracycline chemotherapy). Findings are self-reported; comparisons exploratory. Results One hundred twenty physicians responded (44 cardiologists, 28 oncologists, 27 gynaecologists, 21 internists; 73.3% academic or university hospitals). Risk stratification showed the lowest cardiological involvement (42.9%, 15/35); 51.0% (26/51) of cardiologists and internists performed it themselves or within a team, and 19.6% (10/51) regarded it as the treating oncologist’s task. LVEF-decline thresholds were asked in two non-equivalent versions and are reported separately. Any LVEF decline was regarded as cardiotoxicity by 38.2% (13/34) of cardiologists and 61.5% (8/13) of internists, and by 26.7% (4/15) of gynaecologists and 39.1% (9/23) of oncologists; a decline exceeding 10% points by 55.9% and 23.1%, respectively. Routine strain use was reported by 76.5% (26/34) of cardiologists and 36.4% (4/11) of internists. Twelve-month biomarker testing in this scenario was infrequent even in cardiology (20.6%). Conclusions Among these predominantly academic physicians, risk stratification had the least clearly assigned ownership, the LVEF decline regarded as relevant varied widely within each version, routine strain use differed between cardiology and internal medicine, and late post-treatment biomarker testing was infrequent even in cardiology. These hypothesis-generating findings identify targets—assigned responsibility for risk stratification, explicit LVEF thresholds, implementation of routine strain imaging and structured post-treatment surveillance—whose effect on CTR-CVT outcomes requires prospective testing.