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.
System = Musculoskeletal
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 107 |
Amputation |
Amputation-related complications
Impaired cosmesis
Functional and activity limitations
Residual limb integrity problems
Phantom pain
Neuropathic pain
Musculoskeletal pain
Increased energy expenditure
Impaired quality of life and functional status
Psychological maladjustment
|
Host Factors
Skeletally immature/ growing children
Treatment Factors
Site of amputation:
- Hemipelvectomy
- Trans-femur amputation
- Trans-tibia amputation
Medical Conditions
Obesity
Diabetes
Poor residual limb healing
|
|
History
Phantom pain
Functional and activity limitations
(Yearly)
Physical
Residual limb integrity
(Yearly)
Screening
Prosthetic evaluation
(Every six months until skeletally mature, then yearly thereafter)
|
Health Links
See "Patient Resources" field
Amputation
Counseling
Counsel regarding skin checks, signs of poor prosthetic fit, residual limb and prosthetic hygiene, physical fitness, and importance of maintaining a healthy weight and lifestyle.
Considerations for Further Testing and Intervention
Physical therapy consultation as needed per changing physical status such as weight gain or gait training with a new prosthesis, and for non-pharmacological pain management. Occupational therapy consultation as needed to assist with activities of daily living. Psychological/social work consultation to assist with emotional difficulties related to body image, marriage, pregnancy, parenting, employment, insurance and depression. Vocational counseling/training to identify vocations that will not produce/exacerbate functional limitations.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
System = Cardiovascular
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 108 |
Central venous catheter |
Thrombosis
Vascular insufficiency
Infection of retained cuff or line tract
|
|
|
History
Tenderness or swelling at previous catheter site
(Yearly and as clinically indicated)
Physical
Venous stasis
Swelling
Tenderness at previous catheter site
(Yearly and as clinically indicated)
|
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
System = Urinary
Score = Chronic urinary tract infection: 1
Renal dysfunction: 1
Vesicoureteral reflux: 1
Hydronephrosis: 1
Spontaneous neobladder perforation: 1
Reservoir calculi: 2A
Vitamin B21/folate/carotene deficiency: 2B
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 109 |
Cystectomy
Info Link: All potential late effects for pelvic surgery apply to Cystectomy (see also sections 126-129, below).
|
Cystectomy-related complications
Chronic urinary tract infection
Renal dysfunction
Vesicoureteral reflux
Hydronephrosis
Reservoir calculi
Spontaneous neobladder perforation
Vitamin B12/folate/carotene deficiency
Info Link: Reservoir calculi are stones in the neobladder (a reservoir for urine usually constructed of ileum/colon)
|
|
|
Screening
Urology evaluation
(Yearly)
|
Health Links
See "Patient Resources" field
Cystectomy
Kidney Health
|
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 |
| 110 |
Enucleation |
Impaired cosmesis
Poor prosthetic fit
Orbital hypoplasia
|
Host Factors
Younger age at enucleation
Treatment Factors
Combined with radiation
|
|
Screening
Evaluation by ocularist
Evaluation by ophthalmologist
(Yearly)
|
Health Links
See "Patient Resources" field
Eye Health
Considerations for Further Testing and Intervention
Psychological consultation in patients with emotional difficulties
related to cosmetic and visual impairment. Vocational rehabilitation referral as indicated.
|
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 |
111
(Female) |
Hysterectomy
Info Link: For patients who also underwent oophorectomy, see also: Section 123 (unilateral oophorectomy) or Section 124 (bilateral oophorectomy), below
|
Pelvic floor dysfunction
Urinary incontinence
Sexual dysfunction
|
|
|
History
Psychosocial assessment
Abdominal pain
Urinary leakage
Dyspareunia
(Yearly)
|
Health Links
See "Patient Resources" field
Female Health Issues
Counseling
Counsel patients with ovaries regarding potential for biologic parenthood using gestational surrogate.
Considerations for Further Testing and Intervention
Reproductive endocrinology consultation for patients wishing to pursue pregnancy via gestational surrogate.
|
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 |
| 112 |
Laparotomy |
Adhesions
Bowel obstruction
|
Treatment Factors
Combined with radiation
|
|
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
KUB as clinically indicated for suspected obstruction. Surgical consultation for patients unresponsive to medical management.
|
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 |
| 113 |
Limb sparing procedure |
Complications related to limb sparing procedure
Functional and activity limitations
Contractures
Chronic infection
Chronic pain
Limb length discrepancy
Musculoskeletal pain
Increased energy expenditure
Fibrosis
Prosthetic malfunction (loosening, non-union, fracture) requiring revision, replacement, or amputation
Prosthetic revision required due to growth
Impaired quality of life
Complications with pregnancy/delivery (in female patients with internal hemipelvectomy)
|
Host Factors
Younger age at surgery
Rapid growth spurt
Treatment Factors
Tibial endoprosthesis
Medical Conditions
Endoprosthetic infection
Obesity
Health Behaviors
High level of physical activity (associated with higher risk of loosening)
Low level of physical activity (associated with higher risk of contractures or functional limitations)
|
Treatment Factors
Radiation to extremity
Medical Conditions
Poor healing
Infection of reconstruction
|
History
Functional and activity limitations
(Yearly and as clinically indicated)
Physical
Residual limb integrity
(Yearly and as clinically indicated)
Screening
Radiograph
(Yearly)
Evaluation by orthopedic surgeon
(Every six months until skeletally mature, then yearly)
|
Health Links
See "Patient Resources" field
Limb Sparing Procedures
Counseling
Counsel regarding need for antibiotic prophylaxis prior to dental and invasive procedures.
Considerations for Further Testing and Intervention
Antibiotic prophylaxis prior to dental and invasive procedures. Physical therapy consultation as needed per changes in functional status (such as post-lengthening, revisions, life changes such as pregnancy), and for non-pharmacological pain management. Consider psychological consultation as needed to assist with emotional difficulties related to body image, marriage, pregnancy, parenting, employment, insurance and depression. Vocational counseling/training to identify vocations that will not produce/exacerbate functional limitations.
|
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 |
| 114 |
Nephrectomy |
Renal toxicity
Proteinuria
Hyperfiltration
Renal insufficiency
Hydrocele(males only)
|
Treatment Factors
Combined with other nephrotoxic therapy, such as:
- Cisplatin
- Carboplatin
- Ifosfamide
- Aminoglycosides
- Amphotericin
- Immunosuppressants
- Methotrexate
- Radiation impacting the kidneys
|
|
Physical
Blood pressure
(Yearly)
Testicular exam to evaluate for hydrocele
(Yearly for males)
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
Single Kidney Health
See also: Kidney Health
Counseling
Discuss contact sports, bicycle safety (e.g., avoiding handlebar injuries), and proper use of seatbelts (i.e., wearing lapbelts around hips, not waist). Counsel to use NSAIDs with caution.
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 = CNS
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 115 |
Neurosurgery - Brain |
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 vary with extent of surgery and postoperative complications. In general, mild delays occur in most areas of neuropsychological function compared to healthy children. Extent of deficit depends on age at treatment, intensity of treatment, and time since treatment. New deficits may emerge over time. Neurosensory deficits (i.e., vision, hearing) due to tumor or its therapy may complicate neurocognitive outcomes.
|
Host Factors
Younger age at treatment
Primary CNS tumor
Treatment Factors
Extent and location of resection
Longer elapsed time since therapy
In combination with:
- TBI
- Cranial radiation
- Methotrexate (IT, IO, high-dose IV)
- Cytarabine (high-dose IV)
|
Host Factors
Age <3 years at time of treatment
Supratentorial tumor
Predisposing family history of learning or attention problems
Treatment Factors
Radiation dose >24 Gy to whole brain
Radiation dose >40 Gy to local fields
Medical Conditions
Posterior fossa syndrome
CNS infection
|
History
Educational and/or vocational progress
(Yearly)
Screening
Referral for formal neuropsychological evaluation
(Baseline at entry into long-term followup. 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 |
| 116 |
Neurosurgery - Brain |
Motor and/or sensory deficits
Paralysis
Movement disorders
Ataxia
Eye problems (ocular nerve palsy, gaze paresis, nystagmus, papilledema, optic atrophy)
|
Host Factors
Primary CNS tumor
Medical Conditions
Hydrocephalus
|
Host Factors
Optic pathway tumor
Hypothalamic tumor
Suprasellar tumor (eye problems)
|
Screening
Evaluation by neurologist
(Yearly, until 2 to 3 years after surgery or stable; continue to monitor if symptoms persist)
Evaluation by physiatrist/rehabilitation medicine specialist
(Yearly, or more frequently as clinically indicated in patients with motor dysfunction)
|
Considerations for Further Testing and Intervention
Speech, physical, and occupational therapy in patients with persistent deficits. Consider consultations with nutrition, endocrine, and psychiatry (for obsessive-compulsive behaviors) in patients with hypothalamic-pituitary axis tumors. Ophthalmology evaluation 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 |
| 117 |
Neurosurgery - Brain |
Seizures |
Host Factors
Primary CNS tumor
Treatment Factors
Methotrexate (IV, IT, IO)
|
|
Screening
Evaluation by neurologist
(Every six months for patients with seizure disorder)
|
|
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 |
| 118 |
Neurosurgery - Brain |
Hydrocephalus
Shunt malfunction
|
Host Factors
Primary CNS tumor
|
|
Screening
Abdominal x-ray
(After pubertal growth spurt for patients with shunts to assure distal shunt tubing in peritoneum)
Evaluation by neurosurgeon
(Yearly for patients with shunts)
|
Counseling
Educate patient/family regarding potential symptoms of shunt malfunction.
|
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 |
| 119 |
Neurosurgery - Spinal cord |
Neurogenic bladder
Urinary incontinence
|
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Radiation dose >45 Gy to lumbar and/or sacral spine and/or cauda equina
|
Host Factors
Injury above the level of the sacrum
Treatment Factors
Radiation dose >50 Gy to lumbar and/or sacral spine and/or cauda equina
|
History
Hematuria
Urinary urgency/frequency
Urinary incontinence/retention
Dysuria
Nocturia
Abnormal urinary stream
(Yearly)
|
Health Links
See "Patient Resources" field
Neurogenic Bladder
Counseling
Counsel regarding adequate fluid intake, regular voiding, seeking medical attention for symptoms of voiding dysfunction or urinary tract infection, and compliance with recommended bladder catheterization regimen.
Considerations for Further Testing and Intervention
Urologic consultation for patients with dysfunctional voiding or recurrent urinary tract infections.
|
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 |
| 120 |
Neurosurgery - Spinal cord |
Neurogenic bowel
Fecal incontinence
|
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Radiation dose >50 Gy to bladder, pelvis, or spine
|
Host Factors
Injury above the level of the sacrum
|
History
Chronic constipation
Fecal soiling
(Yearly)
Physical
Rectal exam
(As clinically indicated)
|
Counseling
Counsel regarding benefits of adherence to bowel regimen, including adequate hydration, fiber, laxatives/enemas as clinically indicated.
Considerations for Further Testing and Intervention
GI consultation to establish bowel regimen for patients with chronic impaction or fecal soiling.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
System = CNS
Score = 2A
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
121
(Male) |
Neurosurgery - Spinal cord |
Sexual dysfunction (Male)
Erectile dysfunction
|
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Radiation to bladder, pelvis, or spine
Medical Conditions
Hypogonadism
|
Host Factors
Injury above the level of the sacrum
Treatment Factors
Radiation dose >55 Gy to penile bulb in adult
Radiation dose >45 Gy in prepubertal child
|
History
Sexual function (erections, nocturnal emissions, libido)
Medication use impacting sexual function
(Yearly)
|
Health Links
See "Patient Resources" field
Male Health Issues
Resources
www.urologychannel.com
Considerations for Further Testing and Intervention
Urologic consultation in patients with positive history.
|
| Neurosurgery - Spinal cord |
Sexual dysfunction (Female)
|
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Radiation to bladder, pelvis, or spine
Medical Conditions
Hypogonadism
Vaginal fibrosis/stenosis
Chronic GVHD
|
Host Factors
Injury above the level of the sacrum
|
History
Dyspareunia
Altered or diminished sensation, loss of sensation
Medication use impacting sexual function
(Yearly)
|
|
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 |
122
(Female) |
Oophoropexy
Info Link: If shielding from radiation was incomplete: See also Section 84 (ovarian dysfunction related to radiation). (See related guideline summaries listed at the beginning of the "Major Recommendations" field.) |
Oophoropexy-related complications
Inability to conceive despite normal ovarian function
Dyspareunia
Symptomatic ovarian cysts
Bowel obstruction
Pelvic adhesions
|
Treatment Factors
Ovarian radiation
Tubo-ovarian dislocation, especially with lateral ovarian transposition
|
|
History
Abdominal pain
Pelvic pain
Dyspareunia
Inability to conceive despite normal ovarian function
(Yearly)
|
Considerations for Further Testing and Intervention
Gynecologic consultation for patients with positive history and/or physical findings.
|
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 |
123
(Female) |
Oophorectomy (unilateral) |
Premature menopause
Info Link: Evidence for premature menopause following unilateral oophorectomy is limited and has been extrapolated from the adult literature.
|
Health Behaviors
Smoking
|
Treatment Factors
Combined with:
- Pelvic radiation
- Alkylating agents
- TBI
|
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, and/or 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 currently menstruating women to be cautious about delaying childbearing. Counsel regarding need for contraception.
Considerations for Further Testing and Intervention
Refer to reproductive endocrinology for counseling regarding oocyte cryopreservation in patients wishing to preserve options for future fertility.
|
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 |
124
(Female) |
Oophorectomy (bilateral) |
Hypogonadism
Infertility
|
|
|
Screening
Gynecologic or endocrinologic consultation for initiation of HRT
(At age 11)
|
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 benefits of HRT in promoting pubertal progression, bone and cardiovascular health. Counsel women regarding pregnancy potential with donor eggs (if uterus is intact).
Considerations for Further Testing and Intervention
Bone density evaluation for osteopenia/osteoporosis in hypogonadal patients. Reproductive endocrinology referral regarding assisted reproductive technologies.
|
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 |
125
(Male) |
Orchiectomy |
Hypogonadism
Infertility
|
Treatment Factors
Unilateral orchiectomy combined with pelvic or testicular radiation and/or alkylating agents
|
Treatment Factors
Bilateral orchiectomy
|
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
Semen analysis
(As requested by patient for evaluation of infertility)
FSH, LH, testosterone
(For patient with bilateral orchiectomy, refer to endocrinology at about age 11. For patients with unilateral orchiectomy, obtain as clinically indicated for delayed puberty or signs and symptoms of testosterone deficiency.)
|
Health Links
See "Patient Resources" field
Male Health Issues
Counseling
For patients with single testis - counsel to wear athletic supporter with protective cup during athletic activities.
Considerations for Further Testing and Intervention
Refer to endocrinologist for bilateral orchiectomy, delayed puberty, or persistently abnormal hormone levels. Consider surgical placement of testicular prosthesis.
|
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 |
| 126 |
Pelvic surgery
Info Link: For patients with cystectomy: See also Section 109, above |
Urinary incontinence
Urinary tract obstruction
Info Link: Urinary tract obstruction related to retroperitoneal fibrosis
|
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Retroperitoneal node dissection
Extensive pelvic dissection (e.g., bilateral ureteral re-implantation, retroperitoneal tumor resection):
Radiation to the bladder, pelvis, and/or lumbar-sacral spine
|
|
History
Hematuria
Urinary urgency/frequency
Urinary incontinence/retention
Dysuria
Nocturia
Abnormal urinary stream
(Yearly)
|
Counseling
Counsel regarding adequate fluid intake, regular voiding, seeking medical attention for symptoms of voiding dysfunction or urinary tract infection, compliance with recommended bladder catheterization regimen.
Considerations for Further Testing and Intervention
Urologic consultation for patients with dysfunctional voiding or recurrent urinary tract infections.
|
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 |
| 127 |
Pelvic surgery |
Fecal incontinence |
Host Factors
Tumor adjacent to or compressing spinal cord or cauda equina
Treatment Factors
Radiation to the bladder, pelvis, or spine
|
|
History
Chronic constipation, fecal soiling
(Yearly)
Physical
Rectal exam
(As clinically indicated)
|
Counseling
Counsel regarding benefits of adherence to bowel regimen, including adequate hydration, fiber, laxatives/enemas as clinically indicated.
Considerations for Further Testing and Intervention
GI consultation to establish bowel regimen for patients with chronic impaction or fecal soiling.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
System = Male/Female Reproductive
Score = 2A
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
128
(Male) |
Pelvic surgery |
Sexual dysfunction (Male)
Retrograde ejaculation
Anejaculation
Erectile dysfunction
|
Treatment Factors
Retroperitoneal node dissection
Retroperitoneal tumor resection
Cystectomy
Radical prostatectomy
Tumor adjacent to spine
Radiation to bladder, pelvis, or spine
Medical Conditions
Hypogonadism
|
Host Factors
Extensive presacral tumor resection or dissection
Radiation dose >55 Gy to penile bulb in adult and >45 Gy in prepubertal child
|
History
Sexual function (erections, nocturnal emissions, libido)
Medication use impacting sexual function
Quality of ejaculate (frothy white urine with first void after intercourse suggests retrograde ejaculation)
(Yearly)
|
Health Links
See "Patient Resources" field
Male Health Issues
Resources
www.urologychannel.com
Considerations for Further Testing and Intervention
Urologic consultation in patients with positive history and/or physical exam findings.
|
| Pelvic surgery |
Sexual dysfunction (Female) |
Host Factors
Chronic GVHD
Hypogonadism
Tumor adjacent to spine
Medical Conditions
Radiation to bladder, pelvis, or spine
|
|
History
Dyspareunia
Altered or diminished sensation, loss of sensation
Medication use impacting sexual function
(Yearly)
|
|
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 |
129
(Male) |
Pelvic surgery |
Hydrocele |
Treatment Factors
Retroperitoneal node dissection
|
|
Physical
Testicular exam to evaluate for hydrocele
(Yearly)
|
Considerations for Further Testing and Intervention
Urologic consultation for patients with hydrocele.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
System = Pulmonary
Score = 2A
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 130 |
Pulmonary lobectomy
Pulmonary metastasectomy
Pulmonary wedge resection
|
Pulmonary dysfunction |
Treatment Factors
Combined with pulmonary toxic therapy
- Bleomycin
- Busulfan
- Carmustine (BCNU)
- Lomustine (CCNU)
Medical Conditions
Atopic history
Health Behaviors
Smoking
|
Treatment Factors
Combined with:
|
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. 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.
System = Immune
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 131 |
Splenectomy |
Asplenia
At risk for life-threatening infection with encapsulated organisms (e.g., Haemophilus influenzae, streptococcus pneumoniae, meningococcus)
|
|
|
Physical
Physical exam at time of febrile illness to evaluate degree of illness and potential source of infection
(When febrile T >101 degrees F)
Screening
Blood culture
(When febrile T >101 degrees F)
|
Health Links
See "Patient Resources" field
Splenic Precautions
Counseling
Medical alert bracelet/card noting 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.
System = Endocrine/Metabolic
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 132 |
Thyroidectomy
Info Link: Total thyroidectomy is uncommon, but if done is associated with the risk of hypoparathyroidism. This complication generally occurs in the early postoperative period and may persist. Patients with a history of total thyroidectomy should be monitored for signs and symptoms of hypoparathyroidism (e.g., paresthesias, muscle cramping, altered mental status, hyperreflexia, tetany, hypocalcemia, and hyperphosphatemia)
|
Hypothyroidism |
|
|
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.
Abbreviations
- BUN, blood urea nitrogen
- Ca, calcium
- CBC, complete blood count
- Cl, chloride
- CNS, central nervous system
- CO2, carbon dioxide
- CXR, chest x-ray
- DLCO, diffusion capacity of carbon monoxide
- DOE, dyspnea on exertion
- FSH, follicle stimulating hormone
- GI, gastrointestinal
- GVHD, graft versus host disease
- Gy, gray
- HIB, Haemophilus influenza b vaccine
- HRT, hormone replacement therapy
- IO, intraosseous
- IT, intrathecal
- IV, intravenous
- K, potassium
- KUB, kidneys, ureter, bladder radiograph
- LH, luteinizing hormone
- Mg, magnesium
- Na, sodium
- NCI, National Cancer Institute
- NSAIDs, non-steroidal anti-inflammatory drugs
- PFTs, pulmonary function tests
- PO4, phosphate
- SOB, shortness of breath
- T, temperature
- T4, thyroxine
- TBI, total body irradiation
- TSH, thyroid stimulating hormone
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.
