Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 137-146: cancer

Complete Summary

GUIDELINE TITLE

Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 137-146: cancer and general health screening.

BIBLIOGRAPHIC SOURCE(S)

Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Sections 137-146: cancer and general health screening. Bethesda (MD): Children's Oncology Group; 2006 Mar. 11 p. [45 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.

COMPLETE SUMMARY CONTENT

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)

General health and common adult onset cancers, including:

Breast cancer
Cervical cancer
Colorectal cancer
Endometrial cancer
Lung cancer
Oral cancer
Prostate cancer
Skin cancer
Testicular cancer

GUIDELINE CATEGORY

Evaluation
Prevention
Screening

CLINICAL SPECIALTY

Family Practice
Internal Medicine
Obstetrics and Gynecology
Oncology
Pediatrics
Urology

INTENDED USERS

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

GUIDELINE OBJECTIVE(S)

To provide preventive screening recommendations for common adult-onset cancers for 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 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

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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)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

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. 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

Not applicable

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.

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RECOMMENDATIONS

MAJOR RECOMMENDATIONS

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.

Sec #	Organ	At Risk Population	Highest Risk Factors	Periodic Evaluation	Health Counseling Further Considerations
137 (Female)	Breast	Over age 40 Family history of breast cancer in first degree relative Early onset of menstruation Late onset of menopause (age 55 or older) Older than 30 at birth of first child Never pregnant Obesity Previous breast biopsy with atypical hyperplasia Hormone replacement therapy	Chest radiation with potential impact to the breast (see Section 68; see list of related summaries at the beginning of the "Major Recommendation" field), including >20 Gy to the following fields: Mantle Mini-Mantle Mediastinal Chest (thorax) Axilla BRCA1, BRCA2, ATM mutation	*PATIENTS AT STANDARD RISK (ACS Recommendation)* Physical Clinical breast exam (Every 3 years between ages 20-39, then yearly beginning at age 40) Screening Mammogram (Yearly, beginning at age 40)	Health Links See "Patient Resources" field Breast Cancer (for patients at highest risk only) Counseling For patients at highest risk, counsel to perform breast self-examination monthly, beginning at puberty. For standard risk patients, provide general guidance regarding routine screening beginning at age 40 per current ACS guidelines. Considerations for Further Testing and Intervention Surgery and/or oncology consultation as clinically indicated.
137 (Female)	Breast			*PATIENTS AT HIGHEST RISK* Physical Breast self exam (Monthly, beginning at puberty) Clinical 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: 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. Mammography is currently limited in its ability to evaluate premenopausal breasts. 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).