Grades of recommendations (1, 2A, 2B, 3) are defined at the end of the "Major Recommendations" field.
Note from the Children's Oncology Group and the National Guideline Clearinghouse (NGC)>: The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (COG LTFU) are organized according to therapeutic exposures; this guideline has been divided into individual summaries. In addition to the current summary, the following are available:
In order to accurately derive individualized screening recommendations for a specific childhood cancer survivor using this guideline, see "Using the COG LTFU Guidelines to Develop Individualized Screening Recommendations" in the original guideline document. (Note: For ease of use, a Patient-Specific Guideline Identification Tool has been developed to streamline the process and is included in Appendix I of the original guideline document.)
Guideline Organization
The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are organized according to therapeutic exposures, arranged by column as follows:
| System |
Body system (e.g., auditory, musculoskeletal) most relevant to each guideline section. |
Score |
Score assigned by expert panel representing the strength of data from the literature linking a specific late effect with a therapeutic exposure coupled with an assessment of the appropriateness of the screening recommendation based on collective clinical experience. |
| Section Number |
Unique identifier for each guideline section corresponding with listing in Index. |
| Therapeutic Agent |
Therapeutic intervention for malignancy, including chemotherapy, radiation, surgery, blood/serum products, hematopoietic cell transplant, and other therapeutic modalities. |
| Risk Factors |
Host factors (e.g., age, sex, race, genetic predisposition), treatment factors (e.g., cumulative dose of therapeutic agent, mode of administration, combinations of agents), medical conditions (e.g., pre-morbid or co-morbid conditions), and health behaviors (e.g., diet, smoking, alcohol use) that may increase risk of developing the complication. |
| Highest Risk Factors |
Conditions (host factors, treatment factors, medical conditions and/or health behaviors) associated with the highest risk for developing the complication. |
| Periodic Evaluations |
Recommended screening evaluations, including health history, physical examination, laboratory evaluation, imaging, and psychosocial assessment. Recommendation for minimum frequency of periodic evaluations is based on risk factors and magnitude of risk, as supported by the medical literature and/or the combined clinical experience of the reviewers and panel of experts. |
Health Counseling/
Further Considerations |
Health Links: Health education materials developed specifically to accompany these guidelines. Title(s) of Health Link(s) relevant to each guideline section are referenced in this column. Health Link documents are included in Appendix II of the original guideline document.
Counseling: Suggested patient counseling regarding measures to prevent/reduce risk or promote early detection of the potential treatment complication.
Resources: See the original guideline document for lists of books and web sites that may provide the clinician with additional relevant information.
Considerations for Further Testing and Intervention: Recommendations for further diagnostic evaluations beyond minimum screening for individuals with positive screening tests, recommendations for consultation and/or referral, and recommendations for management of exacerbating or predisposing conditions.
|
| References |
References are listed immediately following each guideline section in the original guideline document. Included are medical citations that provide evidence for the association of the therapeutic intervention with the specific treatment complication and/or evaluation of predisposing risk factors. In addition, some general review articles have been included in the Reference section of the original guideline document for clinician convenience. |
Note: See the end of the "Major Recommendations" field for explanations of abbreviations included in the summary.
System = Immune
Score = 1
| Sec # |
Therapeutic Agent(s) |
Potential Late Effects |
Risk Factors |
Highest Risk Factors |
Periodic Evaluation |
Health Counseling Further Considerations |
| 3 |
Diagnosed prior to 1972:
Potential exposure to blood/serum products prior to initiation of Hepatitis B screening of blood supply (1972 in the United States—dates may differ in other countries)
Info Link: Since the vast majority of patients received some type of blood product during childhood cancer treatment, screening based on date of diagnosis/treatment is recommended unless there is absolute certainty that the patient did not receive any blood or blood products. Relevant exposures include packed red cells, whole blood, granulocytes, platelets, fresh frozen plasma, cryoprecipitate, IVIG, VZIG, factor concentrates, and allogeneic marrow, cord blood, or stem cells.
|
Chronic Hepatitis B |
Host Factors
Living in hyperendemic area
Treatment Factors
Blood products before 1972
Health Behaviors
IV drug use
Unprotected sex
Multiple partners
High-risk sexual behavior
Sexually transmitted diseases
Tattoos
Body piercing
|
Host Factors
Chronic immunosuppression
|
Screening
Hepatitis B surface antigen (HBsAg)
Hepatitis B core antibody (anti HBc or HBcAb)
Once in patients who received treatment for cancer prior to 1972.
Note: Date may vary for international patients.
|
Health Links
See "Patient Resources" field
Hepatitis
Considerations for Further Testing and Intervention
Gastroenterology or hepatology consultation for patients with chronic hepatitis. Hepatitis A immunization in patients lacking immunity.
|
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 |
| 4 |
Diagnosed prior to 1993:
Potential exposure to blood/serum products prior to initiation of Hepatitis C screening of blood supply (1993 in the United States—dates may differ in other countries)
Info Link: Since the vast majority of patients received some type of blood product during childhood cancer treatment, screening based on date of diagnosis/treatment is recommended unless there is absolute certainty that the patient did not receive any blood or blood products. Relevant exposures include packed red cells, whole blood, granulocytes, platelets, fresh frozen plasma, cryoprecipitate, IVIG, VZIG, factor concentrates, and allogeneic marrow, cord blood, or stem cells.
|
Chronic Hepatitis C |
Host Factors
Living in hyperendemic area
Treatment Factors
Blood products before 1993
Health Behaviors
IV drug use
Unprotected sex
Multiple partners
High-risk sexual behavior
Sexually transmitted diseases
Tattoos
Body piercing
|
Host Factors
Chronic immunosuppression
Treatment Factors
Blood products prior to 1986 (when surrogate screening of blood donors with ALT was initiated and donors with self-reported high-risk behaviors were deferred)
|
Screening
Hepatitis C antibody
Once in patients who received treatment for cancer prior to 1993.
Note: Date may vary for international patients.
Hepatitis C PCR (to establish chronic infection)
(Once in patients with positive Hepatitis C antibody)
|
Health Links
See "Patient Resources" field
Hepatitis
Considerations for Further Testing and Intervention
Screen for viral hepatitis in patients with persistently abnormal liver function regardless of transfusion history. Consider HCV PCR screening in transfused at-risk HCV-antibody negative patients with abnormal liver function and/or persistent immunosuppression (e.g., HCT recipients with chronic GVHD).
Gastroenterology or hepatology consultation for management of patients with chronic hepatitis. Hepatitis A and B immunization in patients lacking immunity.
|
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 |
| 5 |
Diagnosed between 1977 and 1985:
Potential exposure to blood/serum products prior to initiation of HIV screening of blood supply (between 1977 and 1985 in the United States—dates may differ in other countries)
Info Link: Since the vast majority of patients received some type of blood product during childhood cancer treatment, screening based on date of diagnosis/treatment is recommended unless there is absolute certainty that the patient did not receive any blood or blood products. Relevant exposures include packed red cells, whole blood, granulocytes, platelets, fresh frozen plasma, cryoprecipitate, IVIG, VZIG, factor concentrates, and allogeneic marrow, cord blood, or stem cells.
|
HIV infection |
Treatment Factors
Blood products between 1977 and 1985
Medical Conditions
HPV infection
Health Behaviors
IV drug use
Unprotected sex
Multiple partners
High-risk sexual behavior
Sexually transmitted diseases
Tattoos
Body piercing
|
|
Screening
HIV 1 & 2 antibodies
Once in patients who received treatment for cancer between 1977 and 1985.
Note: Dates may vary for international patients.
|
Counseling
Standard counseling regarding safe sex, universal precautions, and high-risk behaviors that exacerbate risk
Considerations for Further Testing and Intervention
Infectious disease consultation for patients with chronic infection.
|
Note: See a list of Abbreviations at the end of the "Major Recommendations" field.
Abbreviations
- ALT, alanine aminotransferase
- GVHD, graft versus host disease
- HCT, hematopoietic cell transplant
- HCV, hepatitis C virus
- HIV, human immunodeficiency virus
- HPV, human papilloma virus
- IV, intravenous
- IVIG, intravenous immunoglobulin
- PCR, polymerase chain reaction
- VZIG, varicella zoster immunoglobulin
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.
