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.
|
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).
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
138
(Female) |
Cervical |
Early age at first intercourse
Multiple lifetime sex partners
Smoking
Sexually transmitted diseases
|
Personal history of cervical dysplasia
Prenatal DES exposure
HPV infection
Immunosuppression
Chronic steroid use
HIV positive
Chronic GVHD
|
PATIENTS AT STANDARD RISK (ACS Recommendation)
Physical
Pelvic exam
(Every 1 to 2 years)
Screening
Cervical PAP smear
(Yearly for regular PAP test. Every 2 years for liquid-based PAP test. After age 30, if patient has had 3 consecutive normal annual PAP tests, may screen every 2-3 years [with conventional or liquid-based cervical cytology] or every 3 years [with HPV DNA test plus cervical cytology]).
Info Link:
Begin screening (in patients with a cervix) 3 years after first vaginal intercourse, or at age 21, whichever occurs first.
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers
Considerations for Further Testing and Intervention
Gynecology and/or oncology consultation as clinically indicated.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
139 |
Colorectal |
High fat/low fiber diet
Age >50 years
Obesity
|
Radiation with potential impact to the colon/rectum (see Section 78; see list of related summaries at the beginning of the "Major Recommendation" field), including >30 Gy to the following fields:
- Whole abdomen
- All upper abdominal fields
- Pelvic
- Spine (thoracic, lumbar, sacral)
Personal history of ulcerative colitis, gastrointestinal malignancy, adenomatous polyps, or hepatoblastoma
Familial polyposis
Family history of colorectal cancer or polyps in first degree relative
|
PATIENTS AT STANDARD RISK (ACS Recommendation)
Screening
Option 1: Fecal occult blood (minimum of 3 cards)
(Yearly, beginning at age 50)
AND/OR
Flexible sigmoidoscopy
(Every 5 years, beginning at age 50)
Note: The combination of yearly fecal occult blood testing and every 5 year flexible sigmoidoscopy is preferable to either test done alone.
Option 2: Double contrast barium enema
(Every 5 years, beginning at age 50)
Option 3: Colonoscopy
(Every 10 years, beginning at age 50)
|
Health Links
See "Patient Resources" field
Colorectal Cancer
Considerations for Further Testing and Intervention
Gastroenterology, surgery, and/or oncology consultation as clinically indicated.
|
PATIENTS AT HIGHEST RISK
Screening
Colonoscopy
(Every 5 years [minimum]; more frequently if indicated based on colonoscopy results. Begin monitoring 10 years after
radiation or at age 35, whichever occurs last. Monitor more frequently if clinically indicated. 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.
Info Link:
Reports of gastrointestinal malignancies 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 likely was 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.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
140
(Female) |
Endometrial |
Obesity
Older age
Unopposed estrogen therapy
Tamoxifen
Diabetes
Hypertension
High fat diet
Early menopause
Late menopause
Nulliparity
Infertility
Failure to ovulate
|
History of/at risk for HNPCC |
PATIENTS AT HIGHEST RISK (ACS Recommendation)
Screening
Endometrial biopsy
(Yearly, beginning at age 35 for patients at highest risk)
Info Link:
Women at highest risk should be informed that screening recommendation of endometrial biopsy beginning at age 35 is based on expert opinion in the absence of definitive scientific evidence and the potential benefits, risks, and limitations of testing for early endometrial cancer detection should be discussed.
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
141 |
Lung |
Smoking
Workplace exposures to asbestos, arsenic, radiation
Second hand smoke (in non-smokers)
|
Chest radiation with potential impact to the lung |
PATIENTS AT HIGHEST RISK
History
Cough
Wheezing
SOB
DOE
(Yearly, and as clinically indicated)
Physical
Pulmonary Exam
(Yearly, and as clinically indicated)
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers
Considerations for Further Testing and Intervention
Imaging and surgery and/or oncology consultation as clinically indicated.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
142 |
Oral |
Tobacco use (smoking cigars, cigarettes, or pipes; dipping, chewing)
Alcohol abuse
Excessive sun exposure (increases risk of cancer of lower lip)
HCT (allogeneic > autologous)
|
Head/brain radiation
Neck radiation
TBI
Acute/chronic GVHD
|
PATIENTS AT HIGHEST RISK
Physical
Oral cavity exam
(Yearly)
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers Dental Health
Considerations for Further Testing and Intervention
Head and neck/otolaryngology consultation as indicated.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
143
(Male) |
Prostate |
Older age, with steadily increasing risk after age 40 years. |
African-American race
Family history of prostate cancer in first degree relative
|
ALL PATIENTS
Clinicians should be prepared to discuss prostate cancer testing with patients
Info Link:
The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population. ACS concurs with this conclusion.
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers
Considerations for Further Testing and Intervention
Urology and/or oncology consultation as clinically indicated.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
144 |
Skin |
Light skin color
Chronic exposure to sun
Atypical moles or >50 moles
|
Any history of radiation
Personal history of melanoma or skin cancer
Dysplastic nevi
Family history of melanoma or skin cancer
History of severe sunburn at young age
|
PATIENTS AT STANDARD RISK
Info Link:
The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer. There are no randomized trials or case-control studies that directly examine whether screening by clinicians is associated with improved clinical outcomes such as reduced morbidity or mortality from skin cancer. No studies were found that evaluated whether screening improves the outcomes of these cancers. The ACS recommends skin examination as part of a cancer-related checkup, which should occur on the occasion of the patient's periodic health examination. Self-examination of skin is recommended once a month.
|
Health Links
See "Patient Resources" field
Reducing the Risk of Second Cancers
Skin Health
Considerations for Further Testing and Intervention
Surgery, dermatology, and/or oncology consultation as clinically indicated.
|
PATIENTS AT HIGHEST RISK
Physical
Skin self exam
(Monthly)
Dermatologic exam with attention to skin lesions and pigmented nevi in radiation field
(Yearly)
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
145
(Male) |
Testicular |
Young males |
History of cryptorchidism
History of testicular cancer or carcinoma in-situ in contralateral testis
History of gonadal dysgenesis
Klinefelter's syndrome
Family history of testicular cancer
|
Info Link:
For standard and high risk populations, the USPSTF recommends against routine screening for testicular cancer in asymptomatic adolescent and adult males. In 2004, the USPSTF found no new evidence that screening with clinical examination or testicular self-examination is effective in reducing mortality from testicular cancer. Even in the absence of screening, the current treatment interventions provide very favorable health outcomes. Given the low prevalence of testicular cancer, limited accuracy of screening tests, and no evidence for the incremental benefits of screening, the USPSTF concluded that the harms of screening exceed any potential benefits. ACS also no longer recommends clinical testicular cancer screening or testicular self-examination.
|
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Sec # |
Organ |
At Risk Population |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
146 |
General Health Screening |
|
|
Screening
Refer to USPSTF recommendations at www.ahrq.gov/clinic/uspstfix.htm
(Yearly)
|
Considerations for Further Testing and Intervention
Childhood cancer survivors should receive general health maintenance per standard recommendations for age. Recommended preventive services per the USPSTF include screening for hypertension, obesity, depression, tobacco use, and alcohol misuse. In addition, certain subpopulations require screening for lipid disorders, sexually transmitted diseases, and diabetes mellitus. Others require counseling regarding the prevention of cardiovascular disease, osteoporosis, and other disorders. See www.ahrq.gov/clinic/uspstfix.htm for specific recommendations.
Assess immunization status on all patients; reimmunize as indicated. See http://www.cdc.gov/vaccines/recs/schedules/default.htm for current immunization schedules.
For all HCT patients, reimmunization per CDC Guidelines (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4910a1.htm - see table 4) or EBMT Guidelines (http://www.nature.com/bmt/journal/v23/n7/pdf/1701641a.pdf).
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Abbreviations
- ACS, American Cancer Society
- ATM, ataxia telangiectasia cancer susceptibility gene located on chromosome 11
- BRCA1, breast cancer early onset gene (cancer susceptibility gene located on chromosome 17)
- BRCA2, breast cancer 2 early onset gene (cancer susceptibility gene located on chromosome 13)
- CDC, Centers for Disease Control and Prevention
- DES, diethylstilbestrol
- DNA, deoxyribonucleic acid
- DOE, dyspnea on exertion
- EBMT, European Group for Blood and Marrow Transplantation
- FAP, familial adenomatous polyposis
- GVHD, graft versus host disease
- Gy, gray
- HCT, hematopoietic cell transplant
- HIV, human immunodeficiency virus
- HNPCC, hereditary nonpolyposis colorectal cancer
- HPV, human papilloma virus
- IBD, inflammatory bowel disease
- MRI, magnetic resonance imaging
- PAP, Papanicoulau
- PSA, prostate specific antigen
- SOB, shortness of breath
- TBI, total body irradiation
- USPSTF, United States Preventive Services Task Force