Cardio-Oncology Surveillance States: a mechanism-informed framework for cardiovascular risk across the cancer continuum

Contemporary anticancer therapies are increasingly diverse, yet cardiovascular toxicity (CVT) converges on shared myocardial, vascular, and immune–metabolic pathways. Variability in timing and reversibility limits static, therapy-specific surveillance and underscores the need for mechanism-informed approaches. This review introduces Cardio-Oncology Surveillance States (COSS), a conceptual, dynamic, mechanism-informed framework that characterises cardiovascular risk states across the cancer continuum. By integrating clinical phenotype, treatment exposure, multimodal imaging, biomarkers, and metabolic risk, COSS links biological pathways of injury to identifiable clinical signals and supports risk-adapted surveillance with escalation and de-escalation of monitoring intensity. By recognising bidirectional cancer–cardiovascular biology, this framework extends cardio-oncology beyond treatment-related toxicity and supports a prevention-oriented approach to long-term cardiovascular and oncologic outcomes. Diverse cancer therapies converge on shared myocardial, vascular, and immune injury pathways, limiting therapy-specific surveillance approaches. Cardio-Oncology Surveillance States (COSS) define a dynamic, mechanism-informed framework that aligns monitoring intensity with evolving biological risk. Bidirectional cancer–cardiovascular biology reframes cardio-oncology beyond treatment-related toxicity, positioning prevention as central to long-term outcomes.