For children who survive leukemia, the cancer itself may not be the final threat to their health — the treatments that saved their lives can silently damage their hearts for decades. This tension between cure and long-term cardiovascular harm has driven French pediatric oncologists to formalize a comprehensive cardioprotection framework, one that reframes cardiac monitoring as a lifelong obligation rather than an acute-phase afterthought.
The SFCE Leukemia Committee guidelines center on anthracyclines, still the backbone of pediatric acute leukemia protocols, which carry roughly a 10% risk of heart failure — a risk that escalates sharply once cumulative doxorubicin-equivalent dosing exceeds 300 mg/m². Dexrazoxane, an iron-chelating agent once sidelined by concerns about secondary malignancy risk and potential interference with antitumor efficacy, is now formally rehabilitated. Current evidence supports both its safety profile and its cardioprotective properties, earning a formal recommendation for co-administration when cumulative anthracycline exposure reaches that 300 mg/m² threshold. The guidelines also flag an expanding roster of cardiotoxic agents — tyrosine kinase inhibitors, checkpoint immunotherapies, and CAR-T cell therapies — each requiring individualized surveillance protocols. A key technical upgrade embedded in these recommendations is the elevation of global longitudinal strain (GLS) echocardiography over standard ejection fraction measurement, as GLS detects subclinical myocardial dysfunction considerably earlier.
This framework reflects a maturation in pediatric oncology thinking: survival gains now obligate clinicians to model outcomes across a 60-to-70-year post-treatment horizon. The dexrazoxane rehabilitation is particularly notable — prior regulatory caution in some markets had limited its use precisely where it was most needed. Limitations include the guideline's reliance on committee consensus and observational data rather than uniform randomized trial evidence, and the heart team model it prescribes requires institutional infrastructure not universally available. Still, the integration of GLS monitoring and multidisciplinary cardiac teams represents a pragmatic, evidence-informed evolution that other national bodies are likely to follow.