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:
- Air conduction from 250 to 8000 Hz
- Bone conduction if air conduction thresholds exceed bone by 15 dB at any frequency
- 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.