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Complete Summary

GUIDELINE TITLE

Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 38-91: radiation.

BIBLIOGRAPHIC SOURCE(S)

  • Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 38-91: radiation. Bethesda (MD): Children's Oncology Group; 2006 Mar. 74 p. [360 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 1.2. 2004 Mar.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • September 11, 2007, Rocephin (ceftriaxone sodium): Roche informed healthcare professionals about revisions made to the prescribing information for Rocephin to clarify the potential risk associated with concomitant use of Rocephin with calcium or calcium-containing solutions or products.

COMPLETE SUMMARY CONTENT

 ** REGULATORY ALERT **
 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Late effects resulting from therapeutic exposures to radiation for treatment of pediatric malignancies

Effects include cardiovascular, dermatologic, gastrointestinal, hepatic, hormonal, immunologic, metabolic, neurologic (central, peripheral, cognitive), pulmonary, reproductive (testicular, ovarian, breast), sensory (dental, nasal, ocular, otologic), skeletal, and urologic (urinary, renal), sequelae; and secondary malignancies.

Note: These guidelines are intended for use beginning two or more years following the completion of cancer therapy, and provide a framework for ongoing late effects monitoring in childhood cancer survivors; however, these guidelines are not intended to provide guidance for follow-up of the pediatric cancer survivor's primary disease.

GUIDELINE CATEGORY

Evaluation
Management
Prevention
Screening

CLINICAL SPECIALTY

Cardiology
Dentistry
Dermatology
Endocrinology
Family Practice
Gastroenterology
Internal Medicine
Nephrology
Neurology
Obstetrics and Gynecology
Oncology
Ophthalmology
Otolaryngology
Pediatrics
Physical Medicine and Rehabilitation
Psychiatry
Pulmonary Medicine
Radiation Oncology
Urology

INTENDED USERS

Advanced Practice Nurses
Dentists
Nurses
Physical Therapists
Physician Assistants
Physicians
Speech-Language Pathologists

GUIDELINE OBJECTIVE(S)

  • To provide recommendations for screening and management of late effects in survivors of pediatric malignancies
  • To increase quality of life and decrease complication-related healthcare costs for pediatric cancer survivors by providing standardized and enhanced follow-up care throughout the life-span that (a) promotes healthy lifestyles, (b) provides for ongoing monitoring of health status, (c) facilitates early identification of late effects, and (d) provides timely intervention for late effects

TARGET POPULATION

Asymptomatic survivors of childhood, adolescent, or young adult cancers who were treated with radiation therapy and who present for routine exposure-related medical follow-up

INTERVENTIONS AND PRACTICES CONSIDERED

Thorough history and physical examination and targeted screening evaluations

MAJOR OUTCOMES CONSIDERED

Not stated

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Pertinent information from the published medical literature over the past 20 years (updated as of October 2005) was retrieved and reviewed during the development and updating of these guidelines. For each therapeutic exposure, a complete search was performed via MEDLINE (National Library of Medicine, Bethesda, MD). Keywords included "childhood cancer therapy," "complications," and "late effects," combined with keywords for each therapeutic exposure. References from the bibliographies of selected articles were used to broaden the search.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

"High-level evidence" (recommendation category 1) was defined as evidence derived from high quality case control or cohort studies.

"Lower-level evidence" (recommendation categories 2A and 2B) was defined as evidence derived from non-analytic studies, case reports, case series, and clinical experience.

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The guidelines were scored by the multidisciplinary panel of experts using a modified version of the National Criteria: Comprehensive Cancer Network "Categories of Consensus" system. Each score reflects the expert panel's assessment of the strength of data from the literature linking a specific late effect with a therapeutic exposure, coupled with an assessment of the appropriateness of the screening recommendation based on the expert panel's collective clinical experience. "High-level evidence" (category 1) was defined as evidence derived from high quality case control or cohort studies. "Lower-level evidence" (categories 2A and 2B) was defined as evidence derived from non-analytic studies, case reports, case series and clinical experience. Rather than submitting recommendations representing major disagreements, items scored as "Category 3" were either deleted or revised by the panel of experts to provide at least a "Category 2B" score for all recommendations included in the guidelines.

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

In 2002, the leadership of the Children's Oncology Group Late Effects Committee and Nursing Discipline appointed a 7-member task force, with representation from the Late Effects Committee, Nursing Discipline, and Patient Advocacy Committee. The task force was convened to review and summarize the medical literature and develop a draft of clinical practice guidelines to direct long-term follow-up care for pediatric cancer survivors. The task force followed a modified version of the guideline development process established by the National Comprehensive Cancer Network (NCCN), integrating available literature with expert opinion using reiterative feedback loops.

The original draft went through several iterations within the task force prior to initial review. Multidisciplinary experts in the field, including nurses, physicians (pediatric oncologists and other subspecialists), patient advocates, behavioral specialists, and other healthcare professionals, were then recruited by the task force to provide an extensive, targeted review of the draft, including focused review of selected guideline sections. Revisions were made based on these recommendations. The revised draft was then sent out to additional multidisciplinary experts for further review. A total of 62 individuals participated in the review process. The guidelines subsequently underwent comprehensive review and scoring by a panel of experts in the late effects of pediatric malignancies, comprised of multidisciplinary representatives from the COG Late Effects Committee.

Revisions

In order to keep the guidelines current and clinically meaningful, the COG Late Effects Committee organized 18 multi-disciplinary task forces in March 2004. These task forces were charged with the responsibility for monitoring the medical literature in regard to specific system-related clinical topics relevant to the guidelines (e.g., cardiovascular, neurocognitive, fertility/reproductive), providing periodic reports to the Late Effects Committee, and recommending revisions to the guidelines and their associated health education materials and references (including the addition of therapeutic exposures) as new information became available. Task force members were assigned according to their respective areas of expertise and clinical interest. A list of these task forces and their membership is included in the "Contributors" section of the original guideline document. The revisions incorporated into the current release of these guidelines (Version 2.0 – March 2006) reflect the contributions and recommendations of these task forces.

All revisions proposed by the task forces were evaluated by a panel of experts, and if accepted, assigned a score (see "Rating Scheme for the Strength of the Evidence"). Proposed revisions that were rejected by the expert panel were returned with explanation to the relevant task force chair. If desired, task force chairs were given an opportunity to respond by providing additional justification and resubmitting the rejected task force recommendation(s) for further consideration by the expert panel. A total of 34 sections and 9 Health Links were added to Version 2.0 of these guidelines.

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Each score relates to the strength of the association of the identified late effect with the specific therapeutic exposure based on current literature, and is coupled with a recommendation for periodic health screening based on the collective clinical experience of the panel of experts. This is due to the fact that there are no randomized clinical trials (and none forthcoming in the foreseeable future) on which to base recommendations for periodic screening evaluations in this population; therefore, the guidelines should not be misconstrued as representing conventional "evidence-based clinical practice guidelines" or "standards of care".

Each item was scored based on the level of evidence currently available to support it. Scores were assigned according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus," as follows:

1  There is uniform consensus of the panel that (1) there is high-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

2A  There is uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

2B  There is non-uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

3  There is major disagreement that the recommendation is appropriate.

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

External Peer Review
Internal Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The initial version of the guidelines (Version 1.0 – Children's Oncology Group Late Effects Screening Guidelines) was released to the Children's Oncology Group (COG) membership in March 2003 for a six-month trial period. This allowed for initial feedback from the COG membership, resulting in additional review and revision of the guidelines by the Late Effects Committee prior to public release.

Revisions

All revisions proposed by the task forces were evaluated by a panel of experts, and if accepted, assigned a score (see "Rating Scheme for the Strength of the Evidence"). Proposed revisions that were rejected by the expert panel were returned with explanation to the relevant task force chair. If desired, task force chairs were given an opportunity to respond by providing additional justification and resubmitting the rejected task force recommendation(s) for further consideration by the expert panel.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Grades of recommendations (1, 2A, 2B, 3) are defined at the end of the "Major Recommendations" field.

Note from the Children's Oncology Group and the National Guideline Clearinghouse (NGC): The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (COG LTFU) are organized according to therapeutic exposures; this guideline has been divided into individual summaries. In addition to the current summary, the following are available:

In order to accurately derive individualized screening recommendations for a specific childhood cancer survivor using this guideline, see "Using the COG LTFU Guidelines to Develop Individualized Screening Recommendations" in the original guideline document. (Note: For ease of use, a Patient-Specific Guideline Identification Tool has been developed to streamline the process and is included in Appendix I of the original guideline document.)

Guideline Organization

The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are organized according to therapeutic exposures, arranged by column as follows:

System

Body system (e.g., auditory, musculoskeletal) most relevant to each guideline section.

Score

Score assigned by expert panel representing the strength of data from the literature linking a specific late effect with a therapeutic exposure coupled with an assessment of the appropriateness of the screening recommendation based on collective clinical experience.

Section Number

Unique identifier for each guideline section corresponding with listing in Index.

Therapeutic Agent

Therapeutic intervention for malignancy, including chemotherapy, radiation, surgery, blood/serum products, hematopoietic cell transplant, and other therapeutic modalities.

Risk Factors

Host factors (e.g., age, sex, race, genetic predisposition), treatment factors (e.g., cumulative dose of therapeutic agent, mode of administration, combinations of agents), medical conditions (e.g., pre-morbid or co-morbid conditions), and health behaviors (e.g., diet, smoking, alcohol use) that may increase risk of developing the complication.

Highest Risk Factors

Conditions (host factors, treatment factors, medical conditions and/or health behaviors) associated with the highest risk for developing the complication.

Periodic Evaluations

Recommended screening evaluations, including health history, physical examination, laboratory evaluation, imaging, and psychosocial assessment. Recommendation for minimum frequency of periodic evaluations is based on risk factors and magnitude of risk, as supported by the medical literature and/or the combined clinical experience of the reviewers and panel of experts.

Health Counseling/
Further Considerations

Health Links: Health education materials developed specifically to accompany these guidelines. Title(s) of Health Link(s) relevant to each guideline section are referenced in this column. Health Link documents are included in Appendix II of the original guideline document.
Counseling: Suggested patient counseling regarding measures to prevent/reduce risk or promote early detection of the potential treatment complication.
Resources: See the original guideline document for lists of books and web sites that may provide the clinician with additional relevant information.
Considerations for Further Testing and Intervention: Recommendations for further diagnostic evaluations beyond minimum screening for individuals with positive screening tests, recommendations for consultation and/or referral, and recommendations for management of exacerbating or predisposing conditions.

References

References are listed immediately following each guideline section in the original guideline document. Included are medical citations that provide evidence for the association of the therapeutic intervention with the specific treatment complication and/or evaluation of predisposing risk factors. In addition, some general review articles have been included in the Reference section of the original guideline document for clinician convenience.

Note: See the end of the "Major Recommendations" field for explanations of abbreviations included in the summary.

All Fields (Except TBI)

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
38 All Radiation Fields
(including TBI)

Info Link: General factors influencing radiation toxicity include daily fraction size, cumulative dose, age of patient at irradiation and type of radiation used. Toxicity may not be manifest until growth is completed or patient ages.
Secondary benign or malignant neoplasm
Occurring in or near radiation field

Info Link: Patients with bilateral or familial retinoblastoma (implying a germline mutation) are at increased risk for developing second malignant neoplasms
Host Factors

Cancer predisposing mutation (e.g., p53, RB1, NF1)
Younger age at treatment

Treatment Factors

High cumulative radiation dose
Large radiation treatment volumes
Alkylating agent exposure
Treatment Factors

Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
Physical

Inspection and palpation of skin and soft tissues in irradiated field(s)

(Yearly)

Screening

Other evaluations based on treatment volumes

(See recommendations for specific fields)
Health Links

See "Patient Resources" field

Reducing the Risk of Second Cancers

Considerations for Further Testing and Intervention

There is currently a deficiency in the literature regarding whether or not TBI is a risk factor for the development of breast cancer. Monitoring for breast cancer in females who received TBI should be determined on an individual basis. Surgical and/or oncology consultation as clinically indicated.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
39 All Radiation Fields
(including TBI)
Dysplastic nevi

Skin cancer
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Host Factors

Gorlin's syndrome (nevoid basal cell carcinoma syndrome)
Treatment Factors

Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
History

Skin lesions

Changing moles (asymmetry, bleeding, increasing size, indistinct borders)

(Yearly)

Physical

Dermatologic exam of irradiated fields

(Yearly)
Health Links

See "Patient Resources" field

Skin Health
Reducing the Risk of Second Cancers

Considerations for Further Testing and Intervention

Dermatology consultation for evaluation and monitoring of atypical nevi. Oncology consultation as clinically indicated.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Dermatologic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
40 All Radiation Fields
(including TBI)
Dermatologic changes

Fibrosis
Telangiectasias
Permanent hair loss
Altered skin pigmentation
Host Factors

Younger age at treatment

Treatment Factors

Total radiation dose >40 Gy
Large dose fractions (e.g., >2 Gy per fraction)
Treatment Factors

Radiation dose >50 Gy
Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
Physical

Dermatologic exam of irradiated fields

(Yearly)
Health Links

See "Patient Resources" field

Skin Health

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
41 All Radiation Fields
(including TBI)
Bone malignancies Host Factors

Adolescent at treatment
Cancer-predisposing mutation (e.g., p53, RB1, NF1)

Treatment Factors

Higher radiation dose
Combined with alkylating agents
Treatment Factors

Radiation dose >30 Gy
Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
History

Bone pain (especially in irradiated field)

(Yearly)

Physical

Palpation of bones in irradiated field

(Yearly)
Counseling

Counsel patient to report symptoms promptly (e.g., bone pain, bone mass, persistent fevers)

Considerations for Further Testing and Intervention

X-ray or other diagnostic imaging in patients with clinical symptoms. Oncology consultation as clinically indicated.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Brain/Cranium

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
42 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal

TBI
Brain tumor
(benign or malignant)
Host Factors

Younger age at treatment
Neurofibromatosis

Treatment Factors

Higher radiation dose
Host Factors

Age <6 years at time of treatment
Ataxia telangiectasia
History

Headaches

Vomiting

Cognitive, motor, or sensory deficits

Seizures and other neurologic symptoms

(Yearly)

Physical

Neurologic exam

(Yearly)
Considerations for Further Testing and Intervention

Brain MRI as clinically indicated for symptomatic patients. Consider brain MRI every other year for patients with neurofibromatosis beginning 2 years after radiation therapy. Neurosurgical consultation for tissue diagnosis and/or resection. Neuro-oncology consultation for medical management.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
43 Cranial

Ear/Infratemporal

TBI
Neurocognitive deficits

Functional deficits in:
  • Executive function (planning and organization)
  • Sustained attention
  • Memory (particularly visual, sequencing, temporal memory)
  • Processing speed
  • Visual-motor integration

Learning deficits in math and reading (particularly reading comprehension)
Diminished IQ
Behavioral change

Info Link: Neurocognitive deficits in survivors of leukemia and lymphoma are more frequently related to information processing (e.g., learning disability). Neurocognitive deficits in brain tumor survivors treated with higher doses of cranial radiation are more global (significant decline in IQ). Extent of deficit depends on age at treatment, intensity of treatment, and time since treatment. Note: New deficits may emerge over time.
Host Factors

Younger age at treatment
Primary CNS tumor
CNS leukemia/ lymphoma
Relapsed leukemia/lymphoma treated with CNS-directed therapy
Head/neck tumors with brain in radiation field

Treatment Factors

Radiation in combination with:
  • Dexamethasone
  • TBI
  • Methotrexate (IT, IO, high-dose IV)
  • Cytarabine (high-dose IV)

Higher radiation dose
Larger radiation field
Greater cortical volumes
Cranial radiation in combination with TBI
Longer elapsed time since therapy
Host Factors

Age <3 years at time of treatment
Female sex
Supratentorial tumor
Premorbid or family history of learning or attention problems
History

Educational and/or vocational progress

(Yearly)

Screening

Referral for formal neuropsychological evaluation

(Baseline at entry into long-term followup, then periodically as clinically indicated for patients with evidence of impaired educational or vocational progress)
Health Links

See "Patient Resources" field

Educational Issues

Considerations for Further Testing and Intervention

Formal neuropsychological evaluation to include tests of processing speed, computer-based attention, visual motor integration, memory, comprehension of verbal instructions, verbal fluency, executive function and planning. Refer patients with neurocognitive deficits to school liaison in community or cancer center (psychologist, social worker, school counselor) to facilitate acquisition of educational resources and/or social skills training. Consider use of psychotropic medication (e.g., stimulants) or evidence-based rehabilitation training. Caution - lower starting dose and assessment of increased sensitivity when initiating therapy is recommended. Refer to community services for vocational rehabilitation or for services for developmentally disabled.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
44 Cranial Clinical leukoencephalopathy

Spasticity
Ataxia
Dysarthria
Dysphagia
Hemiparesis
Seizures

Info Link: Clinical leukoencephalopathy may present with or without imaging abnormalities (e.g., leukoencephalopathy, cerebral lacunes, cerebral atrophy, dystrophic calcifications, mineralizing microangiopathy). Transient white matter anomalies may follow radiotherapy and high-dose chemotherapy for medulloblastoma/PNET, may mimic tumor recurrence, and signify risk of persistent neurologic sequelae. Neuroimaging changes do not always correlate with degree of cognitive dysfunction. Prospective studies are needed to define the dose/effect relationship of neurotoxic agents. Note: New deficits may emerge over time.
Host Factors

Younger age at treatment
CNS leukemia/lymphoma
Relapsed leukemia/lymphoma treated with CNS-directed therapy

Treatment Factors

In combination with:
  • Dexamethasone
  • Methotrexate (IT, IO, high-dose IV)
  • Cytarabine (high-dose IV)

Higher radiation dose
Larger radiation field
Greater cortical volumes
Longer elapsed time since therapy
Treatment Factors

Radiation dose >24 Gy
Fraction dose >3 Gy
History

Cognitive, motor, and/or sensory deficits

Seizures

Other neurologic symptoms

(Yearly)

Physical

Spasticity

Ataxia

Dysarthria

Hemiparesis

(Yearly)
Considerations for Further Testing and Intervention

Brain MRI, Brain CT with MR angiography as clinically indicated; preferred study based on intracranial lesion to be evaluated:
  • MRI: White matter
  • Gadolinium-enhanced MRI: Microvascular injury
  • CT: Calcifications

Neurology consultation and follow-up as clinically indicated

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = CNS
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
45 >40 Gy to:

Cranial
Orbital/Eye
Ear/Infratemporal
Nasopharyngeal
Cerebrovascular complications

Stroke
Moyamoya
Occlusive cerebral vasculopathy

Info Link: Moyamoya syndrome is the complete occlusion of one or more of the three major cerebral vessels with the development of small, immature collateral vessels, which reflect an attempt to revascularize the ischemic portion of the brain.
Host Factors

Down syndrome

Treatment Factors

Suprasellar radiation

Medical Conditions

Sickle cell disease
Neurofibromatosis
Treatment Factors

Radiation dose >55 Gy
History

Hemiparesis

Hemiplegia

Weakness

Aphasia

(Yearly)

Physical

Neurologic exam

(Yearly)
Considerations for Further Testing and Intervention

Brain MRI with diffusion-weighted imaging with MR angiography as clinically indicated. Neurology/ neurosurgery consultation and follow-up. Physical and occupational therapy as clinically indicated. Note: Revascularization procedures are likely helpful for moyamoya. Aspirin prophylaxis has not yet been shown to be beneficial for moyamoya or occlusive cerebral vasculopathy.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Musculoskeletal
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
46 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Craniofacial abnormalities Host Factors

Younger age at treatment

Treatment Factors

Higher radiation dose
Host Factors

Age <5 years at time of treatment

Treatment Factors

Radiation dose >30 Gy
History

Psychosocial assessment, with attention to:

Educational and/or vocational progress

Depression

Anxiety

Post-traumatic stress

Social withdrawal

(Yearly)

Physical

Craniofacial abnormalities

(Yearly)
Resources

FACES - The National Craniofacial Association www.faces-cranio.org

Considerations for Further Testing and Intervention

Reconstructive craniofacial surgical consultation. Consultation with psychologist in patients with adjustment disorders related to facial asymmetry/deformity.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Immune
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
47 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Chronic sinusitis Treatment Factors

Radiation dose to sinuses >30 Gy
Radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin)

Medical Conditions

Atopic history
Hypogammaglobulinemia
  History

Rhinorrhea

Postnasal discharge

(Yearly)

Physical

Nasal exam

Sinuses

(Yearly)
Considerations for Further Testing and Intervention

CT scan of sinuses as clinically indicated. Otolaryngology consultation as clinically indicated

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
48 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Overweight

Age 2 to 20 years:
BMI for age >85th to <95th percentile

Age >21 years:
BMI

>25 to 29.9

Obesity

Age 2 to 20 years:
BMI for age >95th percentile

Age >21 years:
BMI ≥ 30

Info Link:

BMI=wt(kg)/ht(m2)
BMI calculator available on-line at:
http://nhlbisupport.com/bmi/

Growth charts for patients <21 years of age available on-line at:

www.cdc.gov/growthcharts
Host Factors

Younger at treatment

Treatment Factors

Higher cranial radiation dose
Combined with corticosteroids

Medical Conditions

Familial dyslipidemia
Growth hormone deficiency
Hypothyroidism
Host Factors

Age <4 years old at time of treatment
Female sex

Treatment Factors

Hypothalamic radiation dose >20 Gy

Medical Conditions

Inability to exercise
Physical

Height

Weight

BMI

Blood pressure

(Yearly)

Screening

Fasting blood glucose

Fasting serum insulin

Fasting lipid profile

(Every 2 years in overweight or obese patients. Every 5 years in patients of normal weight. More frequently if indicated based on patient evaluation.)
Health Links

See "Patient Resources" field

Diet and Physical Activity

Counseling

Counsel regarding obesity-related health risks

Considerations for Further Testing and Intervention

Consider evaluation for other co-morbid conditions including dyslipidemia, hypertension, glucose intolerance, diabetes mellitus, hyperinsulinism, and insulin resistance. Nutritional counseling. Endocrine consultation for patients with dyslipidemia or hyperglycemia.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
49 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal

TBI
Metabolic syndrome

Info Link: The metabolic syndrome is a clustering of cardiovascular risk factors that may further increase risk for cardiovascular disease. Definitions of metabolic syndrome are evolving, but generally include a combination of obesity with insulin resistance, dyslipidemia, and elevated blood pressure. Note: Patients who received TBI may develop features of metabolic syndrome without associated obesity.
Treatment Factors

Surgery in suprasellar region
Prolonged corticosteroid therapy (e.g., for chronic GVHD)

Medical Conditions

Growth hormone deficiency
Hypogonadism
Host Factors

Obesity

Treatment Factors

Cranial radiation dose >18 Gy
Physical

Height

Weight

BMI

Blood pressure

(Yearly)

Screening

Fasting blood glucose

Fasting serum insulin

Fasting lipid profile

(Every 5 years. More frequently if indicated based on patient evaluation.)
Health Links

See "Patient Resources" field

Diet and Physical Activity

Counseling

Counsel regarding obesity-related health risks

Considerations for Further Testing and Intervention

Consider endocrine consult if insulin resistance/ metabolic syndrome is suspected. Nutritional counseling. Cardiology consultation as clinically indicated.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Neuroendocrine Axis

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
50 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal

TBI
Growth hormone deficiency

Info Link: Growth charts available on-line at:
www.cdc.gov/growthcharts
Host Factors

Younger at treatment

Treatment Factors

Higher radiation doses
Surgery in suprasellar region
Pretransplant radiation
TBI >10 Gy in single fraction
TBI >12 Gy fractionated
Treatment Factors

Radiation dose >18 Gy
Pretransplant cranial radiation
TBI given in single fraction
History

Assessment of nutritional status

(Every six months until growth is completed, then yearly)

Physical

Height

Weight

BMI

(Every six months until growth is completed, then yearly)

Tanner staging

(Every six months until sexually mature)
Health Links

See "Patient Resources" field

Growth Hormone Deficiency
See also: Hypopituitarism

Resources

www.magicfoundation.org

Considerations for Further Testing and Intervention

Obtain x-ray for bone age in poorly growing children. Endocrine consultation for:
  • Height below 3rd percentile on growth chart
  • Drop >2 percentile rankings on growth chart
  • Growth velocity <4 to 5 cm/year during childhood
  • Lack of pubertal growth spurt

Evaluate thyroid function in any poorly growing child. Consult with endocrinologist regarding risks/benefits of adult growth hormone replacement therapy. Consider bone density testing in patients who are growth hormone deficient.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
51 Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Precocious puberty Host Factors

Female sex
Younger age at treatment

Treatment Factors

Radiation doses >18 Gy
  Physical

Height

Weight

Tanner stage

Testicular volume by Prader orchidometry (males only)

(Yearly until sexually mature)

Screening

FSH

LH

Testosterone (males only)

Estradiol (females only)

(As clinically indicated in patients with signs of accelerated pubertal progression and growth)
Health Links

See "Patient Resources" field

Precocious Puberty

Resources

www.magicfoundation.org

Considerations for Further Testing and Intervention

Obtain x-ray for bone age in rapidly growing children. Endocrine consultation for accelerated puberty (puberty in girl <8 years old or boy <9 years old).

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
52 >40 Gy to:

Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Hyperprolactinemia Treatment Factors

Higher radiation dose
Surgery or tumor in hypothalamic area
Treatment Factors

Radiation dose >50 Gy
History

Galactorrhea

Decreased libido (males)

Menstrual history (females)

(Yearly)

Screening

Prolactin level

(Males with galactorrhea or decreased libido; Females with galactorrhea or amenorrhea)
Health Links

See "Patient Resources" field

Hyperprolactinemia

Resources

www.magicfoundation.org

Considerations for Further Testing and Intervention

CT evaluation of sella turcica for pituitary adenoma in patients with hyperprolactinemia. Endocrine consultation for patients with hyperprolactinemia or galactorrhea (or amenorrhea in females).

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
53 >40 Gy to:

Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Central hypothyroidism

Info Link: Central hypothyroidism includes thyroid-releasing and thyroid-stimulating hormone deficiency
Treatment Factors

Higher radiation dose
  History

Fatigue

Weight gain

Cold intolerance

Constipation

Dry skin

Brittle hair

Depressed mood

(Yearly; Consider more frequent screening during periods of rapid growth)

Physical

Height

Weight

Hair

Skin

Thyroid exam

(Yearly; Consider more frequent screening during periods of rapid growth)

Screening

TSH

Free T4

(Yearly; Consider more frequent screening during periods of rapid growth)
Health Links

See "Patient Resources" field

Thyroid Problems
See also: Hypopituitarism

Counseling

Counsel at-risk females of childbearing potential to have their thyroid levels checked prior to attempting pregnancy and periodically throughout pregnancy.

Considerations for Further Testing and Intervention

Consider TSH surge testing. Endocrine consultation for thyroid hormone replacement.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Male Reproductive/Female Reproductive
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
54 >40 Gy to:

Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Gonadotropin deficiency

Info Link: Gonadotropin deficiency includes LH and FSH deficiency.
Treatment Factors

Higher radiation dose
  MALES:

History

Pubertal (onset, tempo)

Sexual function (erections, nocturnal emissions, libido)

Medication use impacting sexual function

(Yearly)

Physical

Tanner stage

Testicular volume by Prader orchidometry

(Yearly until sexually mature)

Screening

FSH

LH

Testosterone

(Baseline at age 14 and as clinically indicated in patients with delayed puberty and/or clinical signs and symptoms of testosterone deficiency)

Semen analysis

(As requested by patient and for evaluation of infertility)
MALES:

Health Links

See "Patient Resources" field

Male Health Issues
See also: Hypopituitarism

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Considerations for Further Testing and Intervention

Refer to endocrinologist for delayed puberty or persistently abnormal hormone levels. Hormonal replacement therapy for hypogonadal patients. Reproductive endocrinology referral for infertility evaluation and consultation regarding assisted reproductive technologies. Consider bone density testing in patients who are gonadotropin deficient.
FEMALES:

History

Pubertal (onset, tempo)

Menstrual/pregnancy history

Sexual function (vaginal dryness, libido)

Medication use impacting sexual function

(Yearly)

Physical

Tanner stage

(Yearly until sexually mature)

Screening

FSH

LH

Estradiol

(Baseline at age 13, and as clinically indicated in patients with delayed puberty, irregular menses, primary or secondary amenorrhea, or clinical signs and symptoms of estrogen deficiency)
FEMALES:

Health Links

See "Patient Resources" field

Female Health Issues
See also: Hypopituitarism

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Considerations for Further Testing and Intervention

Refer to endocrinologist for delayed puberty or persistently abnormal hormone levels. Hormonal replacement therapy for hypogonadal patients. Reproductive endocrinology referral for infertility evaluation and consultation regarding assisted reproductive technologies. Consider bone density testing in patients who are gonadotropin deficient.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
55 >40 Gy to:

Cranial

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal
Central adrenal insufficiency Treatment Factors

Higher radiation dose
Surgery or tumor in the suprasellar region
Treatment Factors

Prior development of another hypothalamic-pituitary endocrinopathy
History

Failure to thrive

Anorexia

Dehydration

Hypoglycemia

Lethargy

Unexplained hypotension

(Yearly)

Screening

8:00 a.m. serum cortisol

(Yearly for at least 15 years after treatment and as clinically indicated)
Health Links

See "Patient Resources" field

Central Adrenal Insufficiency
See also: Hypopituitarism

Resources

www.magicfoundation.org

Counseling

Counsel regarding corticosteroid replacement therapy and stress dosing. Counsel regarding Medical Alert bracelet.

Considerations for Further Testing and Intervention

Endocrine consultation for further evaluation and replacement steroids

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Eye

System = Ocular
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
56 Cranial

Orbital/Eye

TBI


Info Link: Radiation-related ocular complications other than cataracts are generally associated only with orbital/eye radiation or higher dose cranial radiation. However, patients with a history of an ocular tumor (e.g., retinoblastoma) are at higher risk for late-onset ocular complications and should receive ongoing follow-up by an ophthalmologist at least annually, and more frequently if clinically indicated.
Cataracts Treatment Factors

Radiation dose >10 Gy
TBI >2 Gy in single fraction
TBI >5 Gy fractionated
Radiation combined with:
  • Corticosteroids
  • Busulfan
  • Longer interval since treatment
Treatment Factors

Radiation dose >15 Gy
Fraction dose >2 Gy
TBI >5 Gy in single fraction
TBI >10 Gy fractionated
Cranial/orbital/eye radiation combined with TBI
History

Visual changes (decreased acuity, halos, diplopia)

(Yearly)

Physical

Visual acuity

Funduscopic exam to evaluate for lens opacity

(Yearly)

Screening

Evaluation by ophthalmologist

(Yearly for patients with ocular tumors [regardless of radiation dose] and for those who received TBI or >30 Gy cranial/orbital/eye radiation. Every 3 years for patients without ocular tumors who received <30 Gy.)
Health Links

See "Patient Resources" field

Cataracts

Considerations for Further Testing and Intervention

Ongoing ophthalmology follow-up for identified problems. Refer patients with visual deficits to school liaison in community or cancer center (psychologist, social worker, school counselor) to facilitate acquisition of educational resources.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Ocular
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
57 >30 Gy to:

Cranial

Orbital/Eye


Info Link: Radiation-related ocular complications other than cataracts are generally associated only with orbital/eye radiation or higher dose cranial radiation. However, patients with a history of an ocular tumor (e.g., retinoblastoma) are at higher risk for late-onset ocular complications and should receive ongoing follow-up by an ophthalmologist at least annually, and more frequently if clinically indicated.
Ocular toxicity

Orbital hypoplasia
Lacrimal duct atrophy
Xerophthalmia (keratoconjunctivitis sicca)
Keratitis
Telangiectasias
Retinopathy
Optic chiasm neuropathy
Enophthalmos
Chronic painful eye
Maculopathy
Papillopathy
Glaucoma

Info Link: Reduced visual acuity may be associated with cataracts, retinal damage, and optic nerve damage.
Treatment Factors

Higher radiation dose
Higher daily fraction dose
Radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin) [problems related to tearing]
Host Factors

Chronic GVHD (xerophthalmia only)

Treatment Factors

Fraction dose >2 Gy
History

Visual changes (decreased acuity, halos, diplopia)

Dry eye

Persistent eye irritation

Excessive tearing

Light sensitivity

Poor night vision

Painful eye

(Yearly)

Physical

Visual acuity

Funduscopic exam

(Yearly)

Screening

Evaluation by ophthalmologist

(Yearly)
Health Links

See "Patient Resources" field

Eye Health

Resources

FACES - The National Craniofacial Association website: www.faces-cranio.org

Considerations for Further Testing and Intervention

Consider every six month ophthalmology evaluation for patients with corneal damage (usually associated with xerophthalmia) or complex ocular problems. Refer patients with visual deficits to school liaison in community or cancer center (psychologist, social worker, school counselor) to facilitate acquisition of educational resources.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Ear

System = Auditory
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
58 >30 Gy to:

Cranial

Ear/Infratemporal

Nasopharyngeal
Ototoxicity

Tympanosclerosis
Otosclerosis
Eustachian tube dysfunction
Conductive hearing loss
Host Factors

Younger age at treatment

Treatment Factors

Higher radiation dose

Medical Conditions

Chronic otitis
Chronic cerumen impaction
Treatment Factors

Dose >50 Gy
History

Hearing difficulties (with/without background noise)

Tinnitus

Vertigo

(Yearly)

Physical

Otoscopic exam

(Yearly)

Screening

Complete pure tone audiogram or brainstem auditory evoked response (BAER, ABR)

(Yearly after completion of therapy for 5 years [for patients <10 years old, continue yearly until age 10], then every 5 years. If hearing loss is detected, test at least yearly or as recommended by audiologist. If clinical suspicion of hearing loss at any time, test as clinically indicated. If audiogram is inconclusive or unevaluable, refer to audiologist for consideration of electrophysiologic testing e.g., OAEs.)

Info Link:

Complete pure tone audiogram should include testing of both ears:
  1. Air conduction from 250 to 8000 Hz
  2. Bone conduction if air conduction thresholds exceed bone by 15 dB at any frequency
  3. Speech discrimination evaluation


OAEs measure outer hair cell function only. Because carboplatin selectively damages inner hair cells, patients treated with carboplatin should not be evaluated with OAEs.
Health Links

See "Patient Resources" field

Hearing Loss

Educational Issues

Considerations for Further Testing and Intervention

Audiology consultation for patients with progressive hearing loss. Otolaryngology consultation for patients with chronic infection, cerumen impaction, or other anatomical problems exacerbating or contributing to hearing loss. Speech and language therapy for children with hearing loss. Refer patients with auditory deficits to school liaison in community or cancer center (psychologist, social worker, school counselor) to facilitate provision of educational resources. Consider specialized evaluation for specific needs and/or preferential classroom seating, FM amplification system, and other educational assistance as indicated.
Sensorineural hearing loss
Tinnitus
Host Factors

Younger age at treatment
CNS tumor
CSF shunting

Treatment Factors

Higher radiation dose
Conventional (non-conformal) radiation
Treatment Factors

Radiation administered prior to platinum chemotherapy
Combined with other ototoxic agents such as:
  • Cisplatin
  • Carboplatin in myeloablative doses
  • Aminoglycosides

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Oral Cavity

System = Dental
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
59 Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle
Xerostomia

Salivary gland dysfunction
Treatment Factors

Head and neck radiation involving the parotid gland
Higher radiation doses
Radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin)
Treatment Factors

Salivary gland dose >30 Gy

Medical Conditions

Chronic GVHD
History

Xerostomia

(Yearly)

Physical

Oral exam

(Yearly)

Screening

Dental exam and cleaning

(Every six months)
Health Links

See "Patient Resources" field

Dental Health

Considerations for Further Testing and Intervention

Supportive care with saliva substitutes, moistening agents, and sialogogues (pilocarpine); Regular dental care including fluoride applications

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Dental
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
60 Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle

TBI
Dental abnormalities

Tooth/root agenesis
Microdontia
Root thinning/ shortening
Enamel dysplasia
Periodontal disease
Dental caries
Malocclusion
Temporomandibular joint dysfunction
Host Factors

Younger age at treatment
Gorlin's syndrome (nevoid basal cell carcinoma syndrome)

Treatment Factors

Higher radiation dose
Host Factors

Age <5 years at time of treatment

Treatment Factors

Dose >10 Gy
Physical

Oral exam

(Yearly)

Screening

Dental exam and cleaning

(Every six months)
Health Links

See "Patient Resources" field

Dental Health

Considerations for Further Testing and Intervention

Regular dental care including fluoride applications. Consultation with orthodontist experienced in management of irradiated childhood cancer survivors. Baseline panorex prior to dental procedures to evaluate root development.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Dental
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
61 >40 Gy to:

Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle
Osteoradionecrosis Treatment Factors

Radiation dose to bone >45 Gy
Treatment Factors

Radiation dose to bone >50 Gy
History

Impaired or delayed healing following dental work

Persistent jaw pain or swelling

Trismus

(As clinically indicated)

Physical

Impaired wound healing

Jaw swelling

Trismus

(As clinically indicated)
Health Links

See "Patient Resources" field

Osteoradionecrosis

Considerations for Further Testing and Intervention

Imaging studies (x-ray, CT scan and/or MRI) may assist in making diagnosis. Surgical biopsy may be needed to confirm diagnosis. Consider hyperbaric oxygen treatments.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Neck/Thyroid

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
62 Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle

TBI
Thyroid nodules Host Factors

Younger age at treatment
Female sex

Treatment Factors

Higher radiation dose
Thyroid gland directly in radiation field
TBI
Treatment Factors

Radiation dose to bone >25 Gy
Physical

Thyroid exam

(Yearly)
Health Links

See "Patient Resources" field

Thyroid Problems

Considerations for Further Testing and Intervention

Ultrasound and FNA for evaluation of palpable nodule(s). Endocrine and/or surgical consultation for diagnostic biopsy or thyroidectomy.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
63 Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle

TBI
Thyroid cancer Host Factors

Younger age at treatment
Female sex

Treatment Factors

>5 years after irradiation
Thyroid gland directly in radiation field
TBI
Risk increased up to 30 Gy with a downturn of risk after 30 Gy
  Physical

Thyroid exam

(Yearly)
Health Links

See "Patient Resources" field

Thyroid Problems

Considerations for Further Testing and Intervention

Ultrasound and FNA for evaluation of palpable nodule(s). Surgical consultation for resection. Nuclear medicine consultation for ablation of residual disease. Endocrine consultation for postoperative medical management.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
64 Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle

TBI
Hypothyroidism Host Factors

Female sex

Treatment Factors

Radiation dose >10 Gy
Thyroid gland directly in radiation field
TBI
Treatment Factors

Radiation dose >20 Gy
History

Fatigue

Weight gain

Cold intolerance

Constipation

Dry skin

Brittle hair

Depressed mood

(Yearly; Consider more frequent screening during periods of rapid growth)

Physical

Height

Weight

Hair

Skin

Thyroid exam

(Yearly; Consider more frequent screening during periods of rapid growth)

Screening

TSH

Free T4

(Yearly; Consider more frequent screening during periods of rapid growth)
Health Links

See "Patient Resources" field

Thyroid Problems

Counseling

Counsel at-risk females of childbearing potential to have their thyroid levels checked prior to attempting pregnancy and periodically throughout pregnancy.

Considerations for Further Testing and Intervention

Endocrine consultation for medical management.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Endocrine/Metabolic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
65 >40 Gy to:

Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle
Hypothyroidism Treatment Factors

Higher radiation dose
  History

Heat intolerance

Tachycardia

Palpitations

Weight loss

Emotional lability

Muscular weakness

Hyperphagia

(Yearly)

Physical

Eyes

Skin

Thyroid

Cardiac

Neurologic

(Yearly)

Screening

TSH

Free T4

(Yearly)
Health Links

See "Patient Resources" field

Thyroid Problems

Considerations for Further Testing and Intervention

Endocrine consultation for medical management.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Cardiovascular
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
66 >40 Gy to:

Cranial

Nasopharyngeal

Oropharyngeal

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle
Carotid artery disease     History

Memory impairment

(Yearly)

Physical

Diminished carotid pulses

Carotid bruits

Abnormal neurologic exam (compromise of blood flow to brain)

(Yearly)
Considerations for Further Testing and Intervention

Doppler ultrasound of carotid vessels as clinically indicated. MRI with diffusion-weighted imaging with MR angiography and cardiovascular surgery consultation as clinically indicated. Consider color Doppler 10 years after completion of radiation therapy to the neck as a baseline; refer to cardiologist if abnormal.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Cardiovascular
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
67 >40 Gy to:

Spine (cervical)

Cervical (neck)

Supraclavicular

Mantle

Mini-Mantle
Subclavian artery disease     Physical

Diminished brachial and radial pulses

Pallor of upper extremities

Coolness of skin

Unequal blood pressure

(Yearly)
Considerations for Further Testing and Intervention

Doppler ultrasound of subclavian vessels as clinically indicated. MRI with diffusion-weighted imaging with MR angiography and cardiovascular surgery consultation as clinically indicated. Consider color Doppler 10 years after completion of radiation therapy to the neck as a baseline; refer to cardiologist if abnormal.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Breast

System = SMN
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
68

(Female)
>20 Gy to:

Mantle

Mini-Mantle

Mediastinal

Chest (thorax)

Axilla
Breast cancer Host Factors

Family history of breast cancer

Treatment Factors

Higher radiation dose
Longer time since radiation (>5 years)

Info Link: There is currently a deficiency in the literature regarding whether or not TBI is a risk factor for the development of breast cancer. Monitoring of patients who received TBI should be determined on an individual basis.
Host Factors

Female gender
Physical

Breast exam

(Yearly beginning at puberty until age 25, then every six months)

Screening

Mammogram

(Yearly, beginning 8 years after radiation or at age 25, whichever occurs last)

Info Link: Mammography is currently limited in its ability to evaluate the premenopausal breast. The role of MRI is evolving for screening of other populations at high risk for breast cancer (e.g., premenopausal known or likely carriers of gene mutation of known penetrance).
Health Links

See "Patient Resources" field

Breast Cancer

Counseling

Teach breast self-exam and counsel to perform monthly beginning at puberty.

Considerations for Further Testing and Intervention

Surgical consultation for diagnostic procedure in patients with breast mass or suspicious radiographic finding. Decisions regarding the use of HRT should be based on current literature and should take into consideration the risk/benefit ratio for individual patients.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Female reproductive
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
69

(Female)
>20 Gy to:

Mantle

Mini-Mantle

Mediastinal

Chest (thorax)

Whole lung

Axilla

TBI
Breast tissue hypoplasia Host Factors

Prepubertal at time of breast irradiation

Treatment Factors

Higher radiation dose
  Physical

Breast exam

(Yearly)
Considerations for Further Testing and Intervention

Surgical consultation for breast reconstruction after completion of growth.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Lungs

System = Pulmonary
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
70 Mantle

Mediastinal

Chest (thorax)

Whole lung

TBI
Pulmonary toxicity

Pulmonary fibrosis
Interstitial pneumonitis
Restrictive lung disease
Obstructive lung disease
Host Factors

Younger age at irradiation

Treatment Factors

Radiation dose >10 Gy
Chest radiation combined with TBI
Radiation combined with:
  • Bleomycin
  • Busulfan
  • Carmustine (BCNU)
  • Lomustine (CCNU)
  • Radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin)

Medical Conditions

Atopic history

Health Behaviors

Smoking
Treatment Factors

Radiation dose >15 Gy
TBI >6 Gy in single fraction
TBI >12 Gy fractionated
History

Cough

SOB

DOE

Wheezing

(Yearly)

Physical

Pulmonary exam

(Yearly)

Screening

Chest x-ray

PFTs (including DLCO and spirometry)

(Baseline at entry into long-term follow-up. Repeat as clinically indicated in patients with abnormal results or progressive pulmonary dysfunction.)
Health Links

See "Patient Resources" field

Pulmonary Health

Resources

Extensive information regarding smoking cessation is available for patients on the NCI's website: www.smokefree.gov

Counseling

Counsel regarding tobacco avoidance/smoking cessation. Due to the potential pulmonary toxicity of this therapy, patients who desire to SCUBA dive should be advised to obtain medical clearance from a diving medicine specialist.

Considerations for Further Testing and Intervention

In patients with abnormal PFTs and/or CXR, consider repeat evaluation prior to general anesthesia. Pulmonary consultation for patients with symptomatic pulmonary dysfunction. Influenza and Pneumococcal vaccinations.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Heart

System = Cardiovascular
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
71 Mantle

Mediastinal

Chest (thorax)

Axilla

Spine (thoracic)

Whole abdomen

All upper abdominal fields
Cardiac toxicity

Congestive heart failure
Cardiomyopathy
Pericarditis
Pericardial fibrosis
Valvular disease
Myocardial infarction
Arrhythmia
Atherosclerotic heart disease
Host Factors

Younger age at irradiation
Family history of dyslipidemia
Coronary artery disease

Treatment Factors

Radiation dose >20 Gy to chest
TBI
Combined with radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin)
Combined with other cardiotoxic chemotherapy:
  • Anthracyclines
  • Cyclophosphamide conditioning for HCT
  • Amsacrine

Medical Conditions

Hypertension
Obesity
Dyslipidemia
Diabetes mellitus
Congenital heart disease
Febrile illness
Pregnancy
Premature ovarian failure (untreated)

Health Behaviors

Smoking
Isometric exercise
Drug use (e.g., cocaine, diet pills, ephedra)
Host Factors

Female sex
Black/of African descent
Younger than age 5 years at time of treatment

Treatment Factors

Anteriorly-weighted radiation fields
Lack of subcarinal shielding
Doses >30 Gy in patients who have received anthracyclines
Doses >40 Gy in patients who have not received anthracyclines
Longer time since treatment
History

SOB

DOE

Orthopnea

Chest pain

Palpitations

If under 25 years: Abdominal symptoms (nausea, vomiting)

(Yearly)

Info Link: Exertional intolerance is uncommon in young patients (<25 years). Abdominal symptoms (nausea, emesis) may be observed more frequently than exertional dyspnea or chest pain in young patients.

Physical

Cardiac murmur

S3, S4

Increased P2 sound

Pericardial rub

Rales

Wheezes

Jugular venous distension

Peripheral edema

(Yearly)

Screening

Fasting glucose and lipid profile

(Every 3 to 5 years. If abnormal, refer for ongoing management.)

EKG (include evaluation of QTc interval)

(Baseline at entry into long-term followup. Repeat as clinically indicated.)

ECHO

(Baseline at entry into long-term followup, then periodically based on age at treatment, radiation dose, and cumulative anthracycline dose - see next table.)
Health Links

See "Patient Resources" field

Heart Health
Diet and Physical Activity

Resources

A downloadable wallet card is available from the AHA website for patients requiring endocarditis prophylaxis: www.americanheart.org/downloadable/heart/1023826501754walletcard.pdf

Counseling

Counsel patients with prolonged QTc interval about use of medications that may further prolong the QTc interval (e.g., tricyclic anti-depressants, antifungals, macrolide antibiotics, metronidazole). Counsel regarding maintaining appropriate weight, blood pressure, and heart-healthy diet. Counsel regarding endocarditis prophylaxis if valvular abnormalities present. Counsel regarding appropriate exercise. Aerobic exercise is generally safe and should be encouraged for most patients. Intensive isometric activities (e.g., heavy weight lifting, wrestling) should generally be avoided. Limited high repetition weight lifting (i.e., lifting a lighter weight with ease no more than 15 to 20 times in a row) is much less stressful to the heart and is more likely to be safe. Patients who choose to engage in strenuous or varsity team sports should discuss appropriate guidelines and a plan for ongoing monitoring with a cardiologist.

Considerations for Further Testing and Intervention

Cardiology consultation for patients with subclinical abnormalities on screening evaluations or with left ventricular dysfunction, dysrhythmia or prolonged QTc interval. Additional cardiology evaluation for patients who are pregnant or planning pregnancy who: (1) received >30 Gy chest radiation, or (2) received chest radiation in combination with cardiotoxic chemotherapy (anthracyclines or high-dose cyclophosphamide). Evaluation to include echocardiogram before and periodically during pregnancy (especially during third trimester) and monitoring during labor and delivery due to risk of cardiac failure. Consider cardiology consultation (5 to 10 years after radiation) to evaluate risk for coronary artery disease in patients who received >40 Gy chest radiation alone or >30 Gy chest radiation plus anthracycline. Consider excess risk of isometric exercise program in any high-risk patient defined as needing screening every 1 or 2 years.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Recommended Frequency of Echocardiogram

Age at Treatment* Radiation Dose Anthracycline Dose** Recommended Frequency
<5 years old Any None Every 2 years
Any Every year
>5 years old <30 Gy None Every 5 years
>30 Gy None Every 2 years
Any <300 mg/m2 Every 2 years
>300 mg/m2 Every year
Any age with serial decrease in function Every year

*Age at time of first cardiotoxic therapy (anthracycline or chest radiation, whichever was given first)

**Based on equivalent mg of doxorubicin/daunorubicin

Potential Impact to Spleen

System = Immune
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
72 >40 Gy to:

Spleen (entire)

Whole abdomen

Left upper quadrant

Inverted Y
Functional asplenia

At risk for life-threatening infection with encapsulated organisms (e.g., Haemophilus influenzae, streptococcus pneumoniae, meningococcus)
Treatment Factors

Higher radiation dose to entire spleen
  Physical

Physical exam at time of febrile illness to evaluate degree of illness and potential source of infection (When febrile T >101 degrees F)

(Yearly)

Screening

Blood culture

(When febrile T >101 degrees F)
Health Links

See "Patient Resources" field

Splenic Precautions

Counseling

Medical alert bracelet/card noting functional asplenia; Counsel to avoid malaria and tick bites if living in or visiting endemic areas.

Considerations for Further Testing and Intervention

In patients with T >101 degrees F (38.3 degrees C) or other signs of serious illness, administer a long-acting, broad-spectrum parenteral antibiotic (e.g., ceftriaxone), and continue close medical monitoring while awaiting blood culture results. Hospitalization and broadening of antimicrobial coverage (e.g., addition of vancomycin) may be necessary under certain circumstances, such as the presence of marked leukocytosis, neutropenia, or significant change from baseline CBC; toxic clinical appearance; fever >104 degrees F; meningitis, pneumonia, or other serious focus of infection; signs of septic shock; or previous history of serious infection. Immunize with Pneumococcal, Meningococcal, and HIB vaccines. Pneumovax booster in patients >10 years old at >5 years after previous dose.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to GI/Hepatic System

System = GI/Hepatic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
73 >30 Gy to:

Cervical (neck)

Spine (cervical, thoracic)

Supraclavicular

Mantle

Mini-Mantle

Mediastinal

Chest (thorax)

Whole abdomen

All upper abdominal fields
Esophageal stricture Treatment Factors

Higher radiation dose
Radiomimetic chemotherapy (e.g., doxorubicin, actinomycin)

Medical Conditions

Gastroesophageal reflux
Treatment Factors

Radiation dose >40 Gy
History

Dysphagia

Heartburn

(Yearly)
Health Links

See "Patient Resources" field

Gastrointestinal Health

Considerations for Further Testing and Intervention

Surgical and/or gastroenterology consultation for symptomatic patients.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = GI/Hepatic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
74 >30 Gy to:

Whole abdomen

All upper abdominal fields
Hepatic fibrosis

Cirrhosis
Treatment Factors

Higher radiation dose

Medical Conditions

Chronic hepatitis
History of VOD

Health Behaviors

Alcohol use
Treatment Factors

Dose >40 Gy to at least 1/3 of liver volume
Dose 20 to 30 Gy to entire liver
Physical

Jaundice

Spider angiomas

Palmar erythema

Xanthomata

Hepatomegaly

Splenomegaly

(Yearly)

Screening

ALT

AST

Bilirubin

(Baseline at entry into long-term follow-up. Repeat as clinically indicated.)
Health Links

See "Patient Resources" field

Liver Health

Considerations for Further Testing and Intervention

Prothrombin time for evaluation of hepatic synthetic function in patients with abnormal liver screening tests. Screen for viral hepatitis in patients with persistently abnormal liver function or any patient transfused prior to 1993. Gastroenterology/hepatology consultation in patients with persistent liver dysfunction. Hepatitis A and B immunizations in patients lacking immunity.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = GI/Hepatic
Score = 2B

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
75 >30 Gy to:

Whole abdomen

All upper abdominal fields
Cholelithiasis Host Factors

Ileal conduit
Obesity
Pregnancy
Family history of cholelithiasis

Treatment Factors

Abdominal surgery
Abdominal radiation
TPN
  History

Colicky abdominal pain related to fatty food intake

Excessive flatulence

(Yearly and PRN)

Physical

RUQ or epigastric tenderness

Positive Murphy's sign

(Yearly and PRN)
Health Links

See "Patient Resources" field

Gastrointestinal Health

Considerations for Further Testing and Intervention

Consider gallbladder ultrasound in patients with chronic abdominal pain

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = GI/Hepatic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
76 >30 Gy to:

Whole abdomen

All upper abdominal fields

Pelvic

Spine (thoracic, lumbar, sacral)
Bowel obstruction Treatment Factors

Higher radiation dose to bowel
Abdominal surgery

Info Link: Bowel obstruction is rarely seen in individuals treated with abdominal radiation who have not had abdominal surgery
Treatment Factors

Radiation dose >45 Gy
(Obstruction may occur in people who received lower doses of abdominal radiation during childhood)
History

Abdominal pain

Emesis

Distention

Vomiting

Constipation

(With clinical symptoms of obstruction)

Physical

Tenderness

Abdominal guarding

Distension

(With clinical symptoms of obstruction)
Health Links

See "Patient Resources" field

Gastrointestinal Health

Considerations for Further Testing and Intervention

Obtain KUB in patients with clinical symptoms of obstruction. Surgical consultation in patients unresponsive to medical management.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = GI/Hepatic
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
77 >30 Gy to:

Whole abdomen

All upper abdominal fields

Pelvic

Spine (thoracic, lumbar, sacral)
Chronic enterocolitis

Fistula

Strictures
Treatment Factors

Higher radiation dose to bowel
Abdominal surgery
Treatment Factors

Radiation dose >45 Gy
History

Nausea

Vomiting

Abdominal pain

Diarrhea

(Yearly)
Health Links

See "Patient Resources" field

Gastrointestinal Health

Considerations for Further Testing and Intervention

Serum protein and albumin yearly in patients with chronic diarrhea or fistula. Surgical and/or gastroenterology consultation for symptomatic patients.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = SMN
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
78 >30 Gy to:

Whole abdomen

All upper abdominal fields

Pelvic

Spine (thoracic, lumbar, sacral)
Colorectal cancer

Info Link: Reports of colorectal cancer in cohorts of long-term survivors suggest that radiation likely increases risk, but the median age of onset is not as well established as that of secondary breast cancer following chest radiation. The expert panel agreed that early onset of screening is likely beneficial, and that a prudent course would be to initiate screening for colorectal cancer for those at highest risk (abdominal, pelvic, and/or spinal radiation >30 Gy) at age 35, or 10 years post radiation, whichever occurs last. Surveillance should be done via colonoscopy as per recommendations for populations at highest risk, with information from the first colonoscopy informing the frequency of follow-up testing.
Host Factors

Current age >50 years

Treatment Factors

Higher radiation dose to bowel
Higher daily dose fraction
Combined with chemotherapy (especially alkylators)

Medical Conditions

Obesity

Health Behaviors

High fat/low fiber diet
Host Factors

Personal history of ulcerative colitis, gastrointestinal malignancy, adenomatous polyps, or hepatoblastoma
Familial polyposis
Family history of colorectal cancer or polyps in first degree relative
Screening

Colonoscopy

(Every 5 years [minimum] beginning at 10 years after radiation or at age 35 years [whichever occurs last]; more frequently if indicated based on colonoscopy results; Per the ACS, begin screening earlier for the following high-risk groups - HNPCC: at puberty; FAP: at age 21 years; IBD: 8 years after diagnosis of IBD; Information from the first colonoscopy will inform frequency of follow-up testing)
Health Links

See "Patient Resources" field

Colorectal Cancer

Considerations for Further Testing and Intervention

Surgical and/or oncology consultation as needed.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Urinary Tract

System = Urinary
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
79 Whole abdomen

All upper abdominal fields

TBI

Info Link: Includes all upper abdominal fields except Paraaortic
Renal toxicity

Renal insufficiency
Hypertension
Host Factors

Bilateral Wilms tumor
Mononephric

Treatment Factors

Radiomimetic chemotherapy (e.g., doxorubicin, dactinomycin)
Radiation dose >10 Gy
TBI combined with radiation to the kidney
Combined with other nephrotoxic agents such as:
  • Cisplatin
  • Carboplatin
  • Ifosfamide
  • Aminoglycosides
  • Amphotericin
  • Immunosuppressants

Medical Conditions

Diabetes mellitus
Hypertension
Nephrectomy
Treatment Factors

Radiation dose >15 Gy
TBI >6 Gy in single fraction
TBI >12 Gy fractionated
Physical

Blood pressure

(Yearly)

Screening

BUN

Creatinine

Na, K, Cl, CO2

Ca, Mg, PO4

(Baseline at entry into long-term followup. If abnormal, repeat as clinically indicated.)

Urinalysis

(Yearly)
Health Links

See "Patient Resources" field

Kidney Health
See also: Single Kidney Health

Considerations for Further Testing and Intervention

Nephrology consultation for patients with hypertension, proteinuria, or progressive renal insufficiency

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Urinary
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
80 >30 Gy to:

Whole abdomen

Pelvic

Spine (sacral)
Hemorrhagic cystitis Treatment Factors

Higher radiation dose (>30 Gy to entire bladder; >60 Gy to portion of bladder)
Treatment Factors

Combined with cyclophosphamide and/or ifosfamide
History

Hematuria

Urinary urgency/ frequency

Urinary incontinence/ retention

Dysuria

Nocturia

Abnormal urinary stream

(Yearly)

Screening

Urinalysis

(Yearly)
Health Links

See "Patient Resources" field

Bladder Health

Counseling

Counsel to promptly report dysuria or gross hematuria

Considerations for Further Testing and Intervention

Urine culture, spot urine calcium/creatinine ratio, and ultrasound of kidneys and bladder for patients with microscopic hematuria (defined as ≥ 5 RBC/HPF on at least 2 occasions). Nephrology or Urology referral for patients with culture-negative microscopic hematuria AND abnormal ultrasound and/or abnormal calcium/creatinine ratio. Urology referral for patients with culture negative macroscopic hematuria.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Urinary
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
81 >30 Gy to:

Whole abdomen

Pelvic

Spine (sacral)
Urinary tract toxicity

Bladder fibrosis
Dysfunctional voiding
Vesicoureteral reflux
Hydronephrosis
Treatment Factors

Higher cumulative radiation dose
(>45 Gy)
Radiation to entire bladder
Combined with:
  • Cyclophosphamide
  • Ifosfamide
  • Vincristine
  History

Hematuria

Urinary urgency/ frequency

Urinary incontinence/ retention

Dysuria

Nocturia

Abnormal urinary stream

(Yearly)

Screening

Urinalysis

(Yearly)
Health Links

See "Patient Resources" field

Bladder Health

Considerations for Further Testing and Intervention

Urologic consultation for patients with incontinence or dysfunctional voiding.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = SMN
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
82 Whole abdomen

Pelvic

Spine (sacral)


Info Link: Applies to sacral spine at doses >30 Gy only.
Bladder malignancy Treatment Factors

Radiation to pelvis
Combined with:
  • Cyclophosphamide
  • Ifosfamide

Health Behaviors

Alcohol use
Smoking
  History

Hematuria

Urinary urgency/ frequency

Urinary incontinence/ retention

Dysuria

Nocturia

Abnormal urinary stream

(Yearly)

Screening

Urinalysis

(Yearly)
Health Links

See "Patient Resources" field

Bladder Health

Counseling

Counsel to promptly report dysuria or gross hematuria

Considerations for Further Testing and Intervention

Urine culture, spot urine calcium/creatinine ratio, and ultrasound of kidneys and bladder for patients with microscopic hematuria (defined as >5 RBC/HPF on at least 2 occasions). Nephrology or Urology referral for patients with culture-negative microscopic hematuria AND abnormal ultrasound and/or abnormal calcium/creatinine ratio. Urology referral for patients with culture negative macroscopic hematuria.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Female Reproductive System

System = Female reproductive
Score = 2B

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
83

(Female)
Whole abdomen

Pelvic

Spine (lumbar, sacral)

TBI

Info Link: Applies to all pelvic fields except iliac/inguinal. Applies to lumbar and sacral spine at doses >25 Gy.
Uterine vascular insufficiency
(resulting in adverse pregnancy outcomes, such as spontaneous abortion, neonatal death, low-birth weight infant, fetal malposition, and premature labor)

Info Link: 10% of girls with Wilms tumor have congenital uterine anomalies.
Host Factors

Females with Wilms tumor and associated müllerian anomalies

Treatment Factors

Higher radiation dose to pelvis
Host Factors

Prepubertal at treatment

Treatment Factors

Radiation dose >30 Gy
TBI
History

Pregnancy

Childbirth history

(Yearly and as clinically indicated)
Health Links

See "Patient Resources" field

Female Health Issues

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Considerations for Further Testing and Intervention

Consider high-level ultrasound evaluation of genitourinary tract after pubertal development as clinically indicated in patients contemplating pregnancy. High-risk obstetrical care during pregnancy.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Female reproductive
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
84

(Female)
Whole abdomen

Pelvic

Spine (lumbar, sacral)

TBI

Info Link: Applies to lumbar and sacral spine at doses >25 Gy only.
Gonadal dysfunction (ovarian)

Delayed/arrested puberty
Premature menopause
Infertility
Host Factors

Older age at irradiation

Treatment Factors

Prepubertal female: Radiation dose >10 Gy
Pubertal female: Radiation dose >5 Gy
Combined with alkylating agent chemotherapy
Longer time since treatment
Treatment Factors

Prepubertal female: Radiation dose >15 Gy
Pubertal female: Radiation dose >10 Gy
Combined with cyclophosphamide conditioning for HCT
History

Pubertal (onset, tempo)

Menstrual/ pregnancy history

Sexual function (vaginal dryness, libido)

Medication use impacting sexual function

(Yearly)

Physical

Tanner stage

(Yearly until sexually mature)

Screening

FSH

LH

Estradiol

(Baseline at age 13, and as clinically indicated in patients with delayed puberty, irregular menses or primary or secondary amenorrhea, clinical signs and symptoms of estrogen deficiency)
Health Links

See "Patient Resources" field

Female Health Issues

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Counseling

Counsel regarding the need for contraception, since there is tremendous individual variability in gonadal toxicity after exposure to radiation. Recovery of fertility may occur years after therapy. Counsel regarding risks and benefits of HRT.

Considerations for Further Testing and Intervention

Refer to endocrinologist for delayed/arrested puberty or persistently abnormal hormone levels. Gynecology or endocrinology consultation for HRT. Consider evaluation for conditions exacerbated by hypogonadism (e.g., osteopenia/osteoporosis). Reproductive endocrinology consultation for infertile couples interested in assisted reproductive technologies.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Female reproductive
Score = 2A

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
85

(Female)
Pelvic Vaginal fibrosis/stenosis Host Factors

Vaginal tumor or pelvic tumor adjacent to vagina

Treatment Factors
Prepubertal female: Radiation dose >25 Gy
Postpubertal female: Radiation dose >50 Gy

Medical Conditions

Chronic GVHD
Treatment Factors

Prepubertal female: Radiation dose >35 Gy
Postpubertal female: Radiation dose >55 Gy
History

Psychosocial assessment

Dyspareunia

Vulvar pain

Post-coital bleeding

Difficulty with tampon insertion

(Yearly)
Considerations for Further Testing and Intervention

Gynecologic consultation for management. Psychological consultation in patients with emotional difficulties.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Male Reproductive System

System = Male reproductive
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
86

(Male)
Pelvic

Testicular

TBI
Gonadal dysfunction (testicular):

Germ cell failure

Oligospermia
Azoospermia
Infertility
Treatment Factors

Radiation dose to testes:
  • 1 to 3 Gy: Azoospermia may be reversible
  • 3 to 6 Gy: Azoospermia possibly reversible (but unlikely)
Treatment Factors

Radiation dose to testes >6 Gy: Azoospermia likely permanent
Screening

Semen analysis

(As requested by patient and for evaluation of infertility. Periodic evaluation over time is recommended as resumption of spermatogenesis can occur up to 10 years post therapy.)
Health Links

See "Patient Resources" field

Male Health Issues

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Counseling

Counsel regarding the need for contraception, since there is tremendous individual variability in gonadal toxicity after exposure to radiation. Recovery of fertility may occur years after therapy.

Considerations for Further Testing and Intervention

Reproductive endocrinology consultation for infertile couples interested in assisted reproductive technologies. Testing for Inhibin B can be considered in conjunction with FSH as an indicator of germ cell function.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Male reproductive
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
87

(Male)
>20 Gy to:

Pelvic
Testicular
Gonadal dysfunction (testicular):

Leydig cell dysfunction

Delayed/arrested puberty
Hypogonadism
Treatment Factors

Testicular irradiation combined with head/brain irradiation
Treatment Factors

Combined with:
  • Alkylating agents
  • Cyclophosphamide conditioning for HCT
History

Pubertal (onset, tempo)

Sexual function (erections, nocturnal emissions, libido)

Medication use impacting sexual function

(Yearly)

Physical

Tanner stage

Testicular volume by Prader orchidometry

(Yearly until sexually mature)

Screening

FSH, LH, testosterone

(Baseline at age 14, and as clinically indicated in patients with delayed puberty or clinical signs and symptoms of testosterone deficiency)
Health Links

See "Patient Resources" field

Male Health Issues

Resources

American Society for Reproductive Medicine: www.asrm.org
Fertile Hope: www.fertilehope.org

Considerations for Further Testing and Intervention

Refer to endocrinologist for delayed puberty or persistently abnormal hormone levels. Urology or endocrinology consultation for HRT. Consider evaluation for conditions exacerbated by hypogonadism (e.g., osteopenia/osteoporosis).

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Potential Impact to Musculoskeletal System

System = Musculoskeletal
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
88 All neck fields

All chest fields

Whole abdomen

All upper abdominal fields

All extremity fields

Pelvic

All spinal fields

Info Link: Applies to spine at doses >12 Gy only.
Musculoskeletal growth problems

Hypoplasia
Fibrosis
Reduced or uneven growth
Shortened trunk height (trunk radiation)
Limb length discrepancy (extremity radiation)
Host Factors

Younger age at treatment

Treatment Factors

Higher cumulative radiation dose
Larger radiation treatment field
Higher radiation dose per fraction
Host Factors

Prepubertal at treatment

Treatment Factors

Epiphysis in treatment field
Dose >20 Gy
Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
History

Height

Weight

(Yearly)

Sitting height

(Yearly for patients who had trunk radiation)

Limb lengths

(Yearly for patients who had extremity radiation)
Counseling

Counsel regarding increased risk of fractures in weight-bearing irradiated bones

Considerations for Further Testing and Intervention

Orthopedic consultation for any deficit noted in growing child. Consider plastic surgery consult for reconstruction.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Musculoskeletal
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
89 Mantle
Mini-Mantle
Mediastinal
Whole lung
Chest (thorax)
Whole abdomen


All upper abdominal fields

Pelvic

Spine (lumbar, sacral, thoracic)

Info Link: Applies to spine at doses >12 Gy only.
Scoliosis Host Factors

Younger age at irradiation
Paraspinal malignancies

Treatment Factors

Hemithoracic or abdominal radiation
Hemithoracic, abdominal or spinal surgery
Radiation of only a portion of (rather than whole) vertebral body

Info Link: With contemporary treatment approaches, scoliosis is infrequently seen as a consequence of radiation unless the patient has also undergone surgery to the hemithorax, abdomen or spine
Treatment Factors

Radiation doses >20 Gy (lower doses for infants)
Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
Physical

Spine exam for scoliosis

(Yearly until growth completed. May need more frequent assessment during puberty.)
Health Links

See "Patient Resources" field

Scoliosis and Kyphosis

Considerations for Further Testing and Intervention

Spine films in patients with clinically apparent curve. Orthopedic consultation as indicated based on radiographic exam.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Musculoskeletal
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
90 Mantle
Mini-Mantle
Mediastinal
Whole lung
Chest (thorax)
Whole abdomen


All upper abdominal fields

Spine (thoracic)

Info Link: Applies to thoracic spine at doses >30 Gy only.
Kyphosis Host Factors

Younger age at irradiation
Paraspinal malignancies
Neurofibromatosis
Treatment Factors

Radiation doses >20 Gy (lower doses for infants)
Orthovoltage radiation (commonly used before 1970) due to delivery of greater dose to skin and bones
Physical

Spine exam for kyphosis

(Yearly until growth completed. May need more frequent assessment during puberty.)
Health Links

See "Patient Resources" field

Scoliosis and Kyphosis

Considerations for Further Testing and Intervention

Spine films in patients with clinically apparent curve. Orthopedic consultation as indicated based on radiographic exam.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

System = Musculoskeletal
Score = 1

Sec # Therapeutic Agent(s) Potential Late Effects Risk Factors Highest Risk Factors Periodic Evaluation Health Counseling Further Considerations
91 >40 Gy to:

All neck fields

All chest fields

Whole abdomen

All upper abdominal fields

Pelvic

All spinal fields

All extremity fields
Radiation-induced fracture Treatment Factors

History of surgery to cortex of bone
Treatment Factors

Radiation doses >50 Gy to bone
Physical

Pain, swelling, deformity of bone (As Indicated)
Considerations for Further Testing and Intervention

Radiograph of affected bone as clinically indicated. Orthopedic evaluation as clinically indicated.

Note: See a list of Abbreviations at the end of the "Major Recommendations" field.

Abbreviations

  • ABR, auditory brainstem response
  • ACS, American Cancer Society
  • AHA, American Heart Association
  • BAER, brainstem auditory evoked response
  • BMI, body mass index
  • BUN, blood urea nitrogen
  • Ca, calcium
  • CBC, complete blood count
  • Cl, chloride
  • CNS, central nervous system
  • CO2, carbon dioxide
  • CSF, cerebrospinal fluid
  • CT, computed tomography
  • CXR, chest x-ray
  • dB, decibel
  • DLCO, diffusion capacity of carbon monoxide
  • DOE, dyspnea on exertion
  • ECHO, echocardiogram
  • EKG, electrocardiogram
  • FAP, familial adenomatous polyposis
  • FM, frequency modulation
  • FNA, fine needle aspiration
  • FSH, follicle stimulating hormone
  • GI, gastrointestinal
  • GVHD, graft versus host disease
  • Gy, gray
  • HCT, hematopoietic cell transplant
  • HIB, Haemophilus influenza b vaccine
  • HNPCC, hereditary nonpolyposis colorectal cancer
  • HPF, high power field
  • HRT, hormone replacement therapy
  • HZ, hertz
  • IBD, inflammatory bowel disease
  • IO, intraosseous
  • IQ, intelligence quotient
  • IT, intrathecal
  • IV, intravenous
  • K, potassium
  • KUB, kidney, ureter, and bladder
  • LH, luteinizing hormone
  • Mg, magnesium
  • MR, magnetic resonance
  • MRI, magnetic resonance imaging
  • Na, sodium
  • NCI, National Cancer Institute
  • OAE, otoacoustic emission
  • PFT, pulmonary function test
  • PNET, primitive neuroectodermal tumor
  • PO4, phosphate
  • PRN, as needed
  • RBC, red blood cell
  • RUQ, right upper quadrant
  • SMN, secondary malignant neoplasm
  • SOB, shortness of breath
  • T, temperature
  • T4, thyroxine
  • TBI, total body irradiation
  • TPN, total parenteral nutrition
  • TSH, thyroid stimulating hormone
  • VOD, veno-occlusive disease

Definitions:

Explanation of Scoring for the Long-Term Follow-Up Guidelines

1  There is uniform consensus of the panel that (1) there is high-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

2A  There is uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

2B  There is non-uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure, and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members.

3  There is major disagreement that the recommendation is appropriate.

Rating Scheme for the Strength of the Evidence

"High-level evidence" (recommendation category 1) was defined as evidence derived from high quality case control or cohort studies.

"Lower-level evidence" (recommendation categories 2A and 2B) was defined as evidence derived from non-analytic studies, case reports, case series, and clinical experience.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Although several well-conducted studies on large populations of childhood cancer survivors have demonstrated associations between specific exposures and late effects, the size of the survivor population and the rate of occurrence of late effects does not allow for clinical studies that would assess the impact of screening recommendations on the morbidity and mortality associated with the late effect. Therefore, scoring of each exposure reflects the expert panel's assessment of the level of literature support linking the therapeutic exposure with the late effect coupled with an assessment of the appropriateness of the recommended screening modality in identifying the potential late effect based on the panel's collective clinical experience.

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Potential benefits of implementing these guidelines into clinical practice include earlier identification of and intervention for late onset therapy-related complications in this at-risk population, potentially reducing or ameliorating the impact of late complications on the health status of survivors. In addition, ongoing healthcare that promotes healthy lifestyle choices and provides ongoing monitoring of health status is important for all cancer survivors.

POTENTIAL HARMS

Potential harms of guideline implementation include increased patient anxiety related to enhanced awareness of possible complications, as well as the potential for false-positive screening evaluations, leading to unnecessary further workup. In addition, costs of long-term follow-up care may be prohibitive for some patients, particularly those lacking health insurance, or those with insurance that does not cover the recommended screening evaluations.

QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

  • The information and contents of each document or series of documents made available by the Children's Oncology Group relating to late effects of cancer treatment and care or containing the title "Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers" or the title "Health Link," whether available in print or electronic format (including any digital format, e-mail transmission, or download from the website), shall be known hereinafter as "Informational Content." All Informational Content is for informational purpose only. The Informational Content is not intended to substitute for medical advice, medical care, diagnosis, or treatment obtained from a physician or healthcare provider.
  • To cancer patients (if children, their parents or legal guardians): Please seek the advice of a physician or other qualified healthcare provider with any questions you may have regarding a medical condition and do not rely on the Informational Content. The Children's Oncology Group is a research organization and does not provide individualized medical care or treatment.
  • To physicians and other healthcare providers: The Informational Content is not intended to replace your independent clinical judgment, medical advice, or to exclude other legitimate criteria for screening, health counseling, or intervention for specific complications of childhood cancer treatment. Neither is the Informational Content intended to exclude other reasonable alternative follow-up procedures. The Informational Content is provided as a courtesy, but not intended as a sole source of guidance in the evaluation of childhood cancer survivors. The Children's Oncology Group recognizes that specific patient care decisions are the prerogative of the patient, family, and healthcare provider.
  • While the Children's Oncology Group has made every attempt to assure that the Informational Content is accurate and complete as of the date of publication, no warranty or representation, express or implied, is made as to the accuracy, reliability, completeness, relevance, or timeliness of such Informational Content.
  • No liability is assumed by the Children's Oncology Group or any affiliated party or member thereof for damage resulting from the use, review, or access of the Informational Content. You agree to the following terms of indemnification: (i) "Indemnified Parties" include authors and contributors to the Informational Content, all officers, directors, representatives, employees, agents, and members of the Children's Oncology Group and affiliated organizations; (ii) by using, reviewing, or accessing the Informational Content, you agree, at your own expense, to indemnify, defend and hold harmless Indemnified Parties from any and all losses, liabilities, or damages (including attorneys' fees and costs) resulting from any and all claims, causes of action, suits, proceedings, or demands related to or arising out of use, review or access of the Informational Content.
  • Ultimately, as with all clinical guidelines, decisions regarding screening and clinical management for any specific patient should be individually tailored, taking into consideration the patient's treatment history, risk factors, co-morbidities, and lifestyle. These guidelines are therefore not intended to replace clinical judgment or to exclude other reasonable alternative follow-up procedures. The Children's Oncology Group recognizes that specific patient care decisions are the prerogative of the patient, family, and healthcare provider.

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of these guidelines is intended to standardize and enhance follow-up care provided to survivors of pediatric malignancies throughout the lifespan. Considerations in this regard include the practicality and efficiency of applying these broad guidelines in individual clinical situations. Studies to address guideline implementation and refinement are a top priority of the Children's Oncology Group (COG) Late Effects Committee, and proposals to study feasibility of guideline use in limited institutions are currently underway. Issues to be addressed include description of anticipated barriers to application of the recommendations in the guidelines and development of review criteria for measuring changes in care when the guidelines are implemented. Additional concerns surround the lack of current evidence establishing the efficacy of screening for late complications in pediatric cancer survivors. While most clinicians believe that ongoing surveillance for these late complications is important in order to allow for early detection and intervention for complications that may arise, development of studies addressing the efficacy of this approach is imperative in order to determine which screening modalities are optimal for asymptomatic survivors.

In addition, the clinical utility of this lengthy document has also been a top concern of the COG Late Effects Committee. While recognizing that the length and depth of these guidelines is important in order to provide clinically-relevant, evidence-based recommendations and supporting health education materials, clinician time limitations and the effort required to identify the specific recommendations relevant to individual patients have been identified as barriers to their clinical application. Therefore, the COG Late Effects Committee is currently partnering with the Baylor School of Medicine in order to develop a web-based interface, known as "Passport for Care," that will generate individualized exposure-based recommendations from these guidelines in a clinician-focused format for ease of patient-specific application of the guidelines in the clinical setting. As additional information regarding implementation of the Passport for Care web-based interface becomes available, updates will be posted at www.survivorshipguidelines.org.

IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms
Patient Resources
Resources

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Living with Illness
Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 38-91: radiation. Bethesda (MD): Children's Oncology Group; 2006 Mar. 74 p. [360 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2003 Sep (revised 2006 Mar)

GUIDELINE DEVELOPER(S)

Children's Oncology Group - Medical Specialty Society

SOURCE(S) OF FUNDING

This work was supported by the Children's Oncology Group grant U10 CA098543 from the National Cancer Institute.

GUIDELINE COMMITTEE

Children's Oncology Group Nursing Discipline and Late Effects Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Melissa M. Hudson, MD
Vice-Chair – COG Late Effects Committee
Member, Department of Hematology-Oncology
Director, After Completion of Therapy Clinic
St. Jude Children's Research Hospital
Memphis, Tennessee

Wendy Landier, RN, MSN, CPNP, CPON®
Chair – COG Nursing Clinical Practice Subcommittee
Clinical Director - Survivorship Clinic
City of Hope Comprehensive Cancer Center
Duarte, California

Smita Bhatia, MD, MPH
Chair – COG Late Effects Committee
Professor and Chair, Division of Population Sciences
City of Hope Comprehensive Cancer Center
Duarte, California

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All Children's Oncology Group (COG) members have complied with the COG conflict of interest policy, which requires disclosure of any potential financial or other conflicting interests.

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Version 1.2. 2004 Mar.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

In an effort led by the Nursing Clinical Practice Subcommittee, complementary patient education materials (Health Links) were developed and are available in Appendix II of the original guideline document. The following Health Links are relevant to this summary:

Sections 38, 39

Sections 39, 40

Sections 43, 58

Sections 48, 49, 71

Section 50

Section 51

Section 52

Section 53, 62, 63, 64, 65

Sections 53, 54, 55

Section 50, 54, 86, 87

Sections 54, 83, 84

Section 55

Section 56

Section 57

Section 58

Sections 59, 60

Section 61

Section 68

Section 70

Section 71

Section 72

Sections 73, 75, 76, 77

Section 74

Section 78

Section 79

Sections 80, 81, 82

Sections 89, 90

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS

This NGC summary was completed by ECRI Institute on May 10, 2007. The information was verified by the guideline developer on June 11, 2007. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium).

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
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