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## Complete Summary

#### GUIDELINE TITLE

Long-term follow-up guidelines for survivors of childhood, adolescent,
and young adult cancers. Sections 38-91: radiation.

#### BIBLIOGRAPHIC SOURCE(S)

Children\'s Oncology Group. Long-term follow-up guidelines for survivors
of childhood, adolescent, and young adult cancers. Sections 38-91:
radiation. Bethesda (MD): Children\'s Oncology Group; 2006 Mar. 74 p.
\[360 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Children\'s Oncology Group.
Long-term follow-up guidelines for survivors of childhood, adolescent,
and young adult cancers. Version 1.2. 2004 Mar.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [September 11, 2007, Rocephin (ceftriaxone
    sodium)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Rocephin):
    Roche informed healthcare professionals about revisions made to the
    prescribing information for Rocephin to clarify the potential risk
    associated with concomitant use of Rocephin with calcium or
    calcium-containing solutions or products.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Late effects resulting from therapeutic exposures to radiation for
treatment of pediatric malignancies

Effects include cardiovascular, dermatologic, gastrointestinal, hepatic,
hormonal, immunologic, metabolic, neurologic (central, peripheral,
cognitive), pulmonary, reproductive (testicular, ovarian, breast),
sensory (dental, nasal, ocular, otologic), skeletal, and urologic
(urinary, renal), sequelae; and secondary malignancies.

**Note**: These guidelines are intended for use beginning two or more
years following the completion of cancer therapy, and provide a
framework for ongoing late effects monitoring in childhood cancer
survivors; however, these guidelines are not intended to provide
guidance for follow-up of the pediatric cancer survivor\'s primary
disease.

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Screening

#### CLINICAL SPECIALTY

Cardiology\
Dentistry\
Dermatology\
Endocrinology\
Family Practice\
Gastroenterology\
Internal Medicine\
Nephrology\
Neurology\
Obstetrics and Gynecology\
Oncology\
Ophthalmology\
Otolaryngology\
Pediatrics\
Physical Medicine and Rehabilitation\
Psychiatry\
Pulmonary Medicine\
Radiation Oncology\
Urology

#### INTENDED USERS

Advanced Practice Nurses\
Dentists\
Nurses\
Physical Therapists\
Physician Assistants\
Physicians\
Speech-Language Pathologists

#### GUIDELINE OBJECTIVE(S)

-   To provide recommendations for screening and management of late
    effects in survivors of pediatric malignancies

-   To increase quality of life and decrease complication-related
    healthcare costs for pediatric cancer survivors by providing
    standardized and enhanced follow-up care throughout the life-span
    that (a) promotes healthy lifestyles, (b) provides for ongoing
    monitoring of health status, (c) facilitates early identification of
    late effects, and (d) provides timely intervention for late effects

#### TARGET POPULATION

Asymptomatic survivors of childhood, adolescent, or young adult cancers
who were treated with radiation therapy and who present for routine
exposure-related medical follow-up

#### INTERVENTIONS AND PRACTICES CONSIDERED

Thorough history and physical examination and targeted screening
evaluations

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Pertinent information from the published medical literature over the
past 20 years (updated as of October 2005) was retrieved and reviewed
during the development and updating of these guidelines. For each
therapeutic exposure, a complete search was performed via MEDLINE
(National Library of Medicine, Bethesda, MD). Keywords included
\"childhood cancer therapy,\" \"complications,\" and \"late effects,\"
combined with keywords for each therapeutic exposure. References from
the bibliographies of selected articles were used to broaden the search.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### 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.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The guidelines were scored by the multidisciplinary panel of experts
using a modified version of the National Criteria: Comprehensive Cancer
Network \"Categories of Consensus\" system. Each score reflects the
expert panel\'s assessment of 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 the expert panel\'s collective clinical experience.
\"High-level evidence\" (category 1) was defined as evidence derived
from high quality case control or cohort studies. \"Lower-level
evidence\" (categories 2A and 2B) was defined as evidence derived from
non-analytic studies, case reports, case series and clinical experience.
Rather than submitting recommendations representing major disagreements,
items scored as \"Category 3\" were either deleted or revised by the
panel of experts to provide at least a \"Category 2B\" score for all
recommendations included in the guidelines.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

In 2002, the leadership of the Children\'s Oncology Group Late Effects
Committee and Nursing Discipline appointed a 7-member task force, with
representation from the Late Effects Committee, Nursing Discipline, and
Patient Advocacy Committee. The task force was convened to review and
summarize the medical literature and develop a draft of clinical
practice guidelines to direct long-term follow-up care for pediatric
cancer survivors. The task force followed a modified version of the
guideline development process established by the National Comprehensive
Cancer Network (NCCN), integrating available literature with expert
opinion using reiterative feedback loops.

The original draft went through several iterations within the task force
prior to initial review. Multidisciplinary experts in the field,
including nurses, physicians (pediatric oncologists and other
subspecialists), patient advocates, behavioral specialists, and other
healthcare professionals, were then recruited by the task force to
provide an extensive, targeted review of the draft, including focused
review of selected guideline sections. Revisions were made based on
these recommendations. The revised draft was then sent out to additional
multidisciplinary experts for further review. A total of 62 individuals
participated in the review process. The guidelines subsequently
underwent comprehensive review and scoring by a panel of experts in the
late effects of pediatric malignancies, comprised of multidisciplinary
representatives from the COG Late Effects Committee.

**Revisions**

In order to keep the guidelines current and clinically meaningful, the
COG Late Effects Committee organized 18 multi-disciplinary task forces
in March 2004. These task forces were charged with the responsibility
for monitoring the medical literature in regard to specific
system-related clinical topics relevant to the guidelines (e.g.,
cardiovascular, neurocognitive, fertility/reproductive), providing
periodic reports to the Late Effects Committee, and recommending
revisions to the guidelines and their associated health education
materials and references (including the addition of therapeutic
exposures) as new information became available. Task force members were
assigned according to their respective areas of expertise and clinical
interest. A list of these task forces and their membership is included
in the \"Contributors\" section of the original guideline document. The
revisions incorporated into the current release of these guidelines
(Version 2.0 -- March 2006) reflect the contributions and
recommendations of these task forces.

All revisions proposed by the task forces were evaluated by a panel of
experts, and if accepted, assigned a score (see \"Rating Scheme for the
Strength of the Evidence\"). Proposed revisions that were rejected by
the expert panel were returned with explanation to the relevant task
force chair. If desired, task force chairs were given an opportunity to
respond by providing additional justification and resubmitting the
rejected task force recommendation(s) for further consideration by the
expert panel. A total of 34 sections and 9 Health Links were added to
Version 2.0 of these guidelines.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Each score relates to the strength of the association of the identified
late effect with the specific therapeutic exposure based on current
literature, and is coupled with a recommendation for periodic health
screening based on the collective clinical experience of the panel of
experts. This is due to the fact that there are no randomized clinical
trials (and none forthcoming in the foreseeable future) on which to base
recommendations for periodic screening evaluations in this population;
therefore, the guidelines should not be misconstrued as representing
conventional \"evidence-based clinical practice guidelines\" or
\"standards of care\".

Each item was scored based on the level of evidence currently available
to support it. Scores were assigned according to a modified version of
the National Comprehensive Cancer Network \"Categories of Consensus,\"
as follows:

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.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The initial version of the guidelines (Version 1.0 -- Children\'s
Oncology Group Late Effects Screening Guidelines) was released to the
Children\'s Oncology Group (COG) membership in March 2003 for a
six-month trial period. This allowed for initial feedback from the COG
membership, resulting in additional review and revision of the
guidelines by the Late Effects Committee prior to public release.

**Revisions**

All revisions proposed by the task forces were evaluated by a panel of
experts, and if accepted, assigned a score (see \"Rating Scheme for the
Strength of the Evidence\"). Proposed revisions that were rejected by
the expert panel were returned with explanation to the relevant task
force chair. If desired, task force chairs were given an opportunity to
respond by providing additional justification and resubmitting the
rejected task force recommendation(s) for further consideration by the
expert panel.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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:

-   [Sections 1-2: Any Cancer
    Experience](http://www.guideline.gov/summary/summary.aspx?doc_id=10246&nbr=005395)

-   [Sections 3--5: Blood/Serum
    Products](http://www.guideline.gov/summary/summary.aspx?doc_id=10768&nbr=005596)

-   [Sections 6--37:
    Chemotherapy](http://www.guideline.gov/summary/summary.aspx?doc_id=10770&nbr=005598)

-   [Sections 92--106: Hematopoietic Cell
    Transplant](http://www.guideline.gov/summary/summary.aspx?doc_id=10772&nbr=005600)

-   [Sections 107--132:
    Surgery](http://www.guideline.gov/summary/summary.aspx?doc_id=10773&nbr=005601)

-   [Sections 133--136: Other Therapeutic
    Modalities](http://www.guideline.gov/summary/summary.aspx?doc_id=10774&nbr=005602)

-   [Sections 137--146: Cancer and General Health
    Screening](http://www.guideline.gov/summary/summary.aspx?doc_id=10775&nbr=005603)

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](http://www.survivorshipguidelines.org/pdf/LTFUGuidelines.pdf).
(Note: For ease of use, a Patient-Specific Guideline Identification Tool
has been developed to streamline the process and is included in
[Appendix
I](http://www.survivorshipguidelines.org/pdf/GuidelinesAppendixI.pdf) 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      Therapeutic intervention for malignancy, including chemotherapy,
  Agent**            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     Conditions (host factors, treatment factors, medical conditions and/or
  Factors**          health behaviors) associated with the highest risk for developing the
                     complication.

  **Periodic         Recommended screening evaluations, including health history, physical
  Evaluations**      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           ***Health Links***: Health education materials developed specifically to
  Counseling/\       accompany these guidelines. Title(s) of Health Link(s) relevant to each
  Further            guideline section are referenced in this column. Health Link documents
  Considerations**   are included in [Appendix
                     II](http://www.survivorshipguidelines.org/pdf/GuidelinesAppendixII.pdf)
                     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](#Abbreviations) included in the summary.

**All Fields (Except TBI)**

**System = SMN\
Score = 1**

  -----------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic   **Potential Late **Risk         **Highest Risk **Periodic        **Health
  \#**    Agent(s)**      Effects**        Factors**      Factors**      Evaluation**      Counseling Further
                                                                                           Considerations**
  ------- --------------- ---------------- -------------- -------------- ----------------- ------------------
  38      **All Radiation **Secondary      **Host         **Treatment    **Physical**\     **Health Links**\
          Fields**\       benign or        Factors**\     Factors**\     \                 \
          (including      malignant        \              \              **Inspection and  **See \"Patient
          TBI)\           neoplasm**\      Cancer         Orthovoltage   palpation of skin Resources\"
          \               Occurring in or  predisposing   radiation      and soft tissues  field**\
          **Info Link**:  near radiation   mutation       (commonly used in irradiated     \
          General factors field\           (e.g., p53,    before 1970)   field(s)**\       Reducing the Risk
          influencing     \                RB1, NF1)\     due to         \                 of Second Cancers\
          radiation       **Info Link**:   Younger age at delivery of    (Yearly)\         \
          toxicity        Patients with    treatment\     greater dose   \                 **Considerations
          include daily   bilateral or     \              to skin and    **Screening**\    for Further
          fraction size,  familial         **Treatment    bones          \                 Testing and
          cumulative      retinoblastoma   Factors**\                    **Other           Intervention**\
          dose, age of    (implying a      \                             evaluations based \
          patient at      germline         High                          on treatment      There is currently
          irradiation and mutation) are at cumulative                    volumes**\        a deficiency in
          type of         increased risk   radiation                     \                 the literature
          radiation used. for developing   dose\                         (See              regarding whether
          Toxicity may    second malignant Large                         recommendations   or not TBI is a
          not be manifest neoplasms        radiation                     for specific      risk factor for
          until growth is                  treatment                     fields)           the development of
          completed or                     volumes\                                        breast cancer.
          patient ages.                    Alkylating                                      Monitoring for
                                           agent exposure                                  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](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = SMN\
Score = 1**

  ------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic   **Potential    **Risk       **Highest Risk **Periodic       **Health
  \#**    Agent(s)**      Late Effects** Factors**    Factors**      Evaluation**     Counseling Further
                                                                                      Considerations**
  ------- --------------- -------------- ------------ -------------- ---------------- ------------------
  39      **All Radiation **Dysplastic   **Host       **Treatment    **History**\     **Health Links**\
          Fields**\       nevi**\        Factors**\   Factors**\     \                \
          (including TBI) \              \            \              **Skin           **See \"Patient
                          **Skin         Gorlin\'s    Orthovoltage   lesions**\       Resources\"
                          cancer**\      syndrome     radiation      \                field**\
                          Basal cell     (nevoid      (commonly used **Changing moles \
                          carcinoma\     basal cell   before 1970)   (asymmetry,      Skin Health\
                          Squamous cell  carcinoma    due to         bleeding,        Reducing the Risk
                          carcinoma\     syndrome)    delivery of    increasing size, of Second Cancers\
                          Melanoma                    greater dose   indistinct       \
                                                      to skin and    borders)**\      **Considerations
                                                      bones          \                for Further
                                                                     (Yearly)\        Testing and
                                                                     \                Intervention**\
                                                                     **Physical**\    \
                                                                     \                Dermatology
                                                                     **Dermatologic   consultation for
                                                                     exam of          evaluation and
                                                                     irradiated       monitoring of
                                                                     fields**\        atypical nevi.
                                                                     \                Oncology
                                                                     (Yearly)         consultation as
                                                                                      clinically
                                                                                      indicated.

  ------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Dermatologic\
Score = 1**

  ------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic   **Potential Late   **Risk Factors**     **Highest Risk       **Periodic       **Health
  \#**    Agent(s)**      Effects**                               Factors**            Evaluation**     Counseling Further
                                                                                                        Considerations**
  ------- --------------- ------------------ -------------------- -------------------- ---------------- ------------------
  40      **All Radiation **Dermatologic     **Host Factors**\    **Treatment          **Physical**\    **Health Links**\
          Fields**\       changes**\         \                    Factors**\           \                \
          (including TBI) \                  Younger age at       \                    **Dermatologic   **See \"Patient
                          Fibrosis\          treatment\           Radiation dose       exam of          Resources\"
                          Telangiectasias\   \                    [\>]{.underline}50   irradiated       field**\
                          Permanent hair     **Treatment          Gy\                  fields**\        \
                          loss\              Factors**\           Orthovoltage         \                Skin Health
                          Altered skin       \                    radiation (commonly  (Yearly)         
                          pigmentation       Total radiation dose used before 1970)                     
                                             [\>]{.underline}40   due to delivery of                    
                                             Gy\                  greater dose to skin                  
                                             Large dose fractions and bones                             
                                             (e.g.,                                                     
                                             [\>]{.underline}2 Gy                                       
                                             per fraction)                                              

  ------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = SMN\
Score = 1**

  ----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic   **Potential Late **Risk Factors**      **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**      Effects**                              Factors**            Evaluation**    Counseling Further
                                                                                                      Considerations**
  ------- --------------- ---------------- --------------------- -------------------- --------------- ------------------
  41      **All Radiation **Bone           **Host Factors**\     **Treatment          **History**\    **Counseling**\
          Fields**\       malignancies**   \                     Factors**\           \               \
          (including TBI)                  Adolescent at         \                    **Bone pain     Counsel patient to
                                           treatment\            Radiation dose       (especially in  report symptoms
                                           Cancer-predisposing   [\>]{.underline}30   irradiated      promptly (e.g.,
                                           mutation (e.g., p53,  Gy\                  field)**\       bone pain, bone
                                           RB1, NF1)\            Orthovoltage         \               mass, persistent
                                           \                     radiation (commonly  (Yearly)\       fevers)\
                                           **Treatment           used before 1970)    \               \
                                           Factors**\            due to delivery of   **Physical**\   **Considerations
                                           \                     greater dose to skin \               for Further
                                           Higher radiation      and bones            **Palpation of  Testing and
                                           dose\                                      bones in        Intervention**\
                                           Combined with                              irradiated      \
                                           alkylating agents                          field**\        X-ray or other
                                                                                      \               diagnostic imaging
                                                                                      (Yearly)        in patients with
                                                                                                      clinical symptoms.
                                                                                                      Oncology
                                                                                                      consultation as
                                                                                                      clinically
                                                                                                      indicated.

  ----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Brain/Cranium**

**System = SMN\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic Agent(s)** **Potential   **Risk Factors**     **Highest Risk   **Periodic       **Health Counseling
  \#**                             Late                               Factors**        Evaluation**     Further
                                   Effects**                                                            Considerations**
  ------- ------------------------ ------------- -------------------- ---------------- ---------------- -------------------
  42      **Cranial**\             **Brain       **Host Factors**\    **Host           **History**\     **Considerations
          \                        tumor**\      \                    Factors**\       \                for Further Testing
          **Orbital/Eye**\         (benign or    Younger age at       \                **Headaches**\   and Intervention**\
          \                        malignant)    treatment\           Age \<6 years at \                \
          **Ear/Infratemporal**\                 Neurofibromatosis\   time of          **Vomiting**\    Brain MRI as
          \                                      \                    treatment\       \                clinically
          **Nasopharyngeal**\                    **Treatment          Ataxia           **Cognitive,     indicated for
          \                                      Factors**\           telangiectasia   motor, or        symptomatic
          **TBI**                                \                                     sensory          patients. Consider
                                                 Higher radiation                      deficits**\      brain MRI every
                                                 dose                                  \                other year for
                                                                                       **Seizures and   patients with
                                                                                       other neurologic neurofibromatosis
                                                                                       symptoms**\      beginning 2 years
                                                                                       \                after radiation
                                                                                       (Yearly)\        therapy.
                                                                                       \                Neurosurgical
                                                                                       **Physical**\    consultation for
                                                                                       \                tissue diagnosis
                                                                                       **Neurologic     and/or resection.
                                                                                       exam**\          Neuro-oncology
                                                                                       \                consultation for
                                                                                       (Yearly)         medical management.

  -------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = CNS\
Score = 1**

+---+----------+----------+-------------+-------+-----------+---------+
| * | **The    | **P      | **Risk      | **Hi  | *         | *       |
| * | rapeutic | otential | Factors**   | ghest | *Periodic | *Health |
| S | Ag       | Late     |             | Risk  | Eva       | Cou     |
| e | ent(s)** | E        |             | Fact  | luation** | nseling |
| c |          | ffects** |             | ors** |           | Further |
| \ |          |          |             |       |           | Co      |
| # |          |          |             |       |           | nsidera |
| * |          |          |             |       |           | tions** |
| * |          |          |             |       |           |         |
+===+==========+==========+=============+=======+===========+=========+
| 4 | **Cr     | **Neuroc | **Host      | *     | **H       | *       |
| 3 | anial**\ | ognitive | Factors**\  | *Host | istory**\ | *Health |
|   | \        | def      | \           | Facto | \         | L       |
|   | **Ear/   | icits**\ | Younger age | rs**\ | **Ed      | inks**\ |
|   | Infratem | \        | at          | \     | ucational | \       |
|   | poral**\ | Fu       | treatment\  | Age   | and/or    | **See   |
|   | \        | nctional | Primary CNS | \<3   | v         | \"      |
|   | **TBI**  | deficits | tumor\      | years | ocational | Patient |
|   |          | in:      | CNS         | at    | pr        | Reso    |
|   |          |          | leukemia/   | time  | ogress**\ | urces\" |
|   |          | -   E    | lymphoma\   | of    | \         | f       |
|   |          | xecutive | Relapsed    | treat | (Yearly)\ | ield**\ |
|   |          |          | leukem      | ment\ | \         | \       |
|   |          | function | ia/lymphoma | F     | **Scr     | Educ    |
|   |          |     (    | treated     | emale | eening**\ | ational |
|   |          | planning | with        | sex\  | \         | Issues\ |
|   |          |     and  | C           | Supr  | *         | \       |
|   |          |          | NS-directed | atent | *Referral | **      |
|   |          |    organ | therapy\    | orial | for       | Conside |
|   |          | ization) | Head/neck   | t     | formal    | rations |
|   |          |          | tumors with | umor\ | neuropsyc | for     |
|   |          | -   S    | brain in    | Prem  | hological | Further |
|   |          | ustained | radiation   | orbid | eval      | Testing |
|   |          |     a    | field\      | or    | uation**\ | and     |
|   |          | ttention | \           | f     | \         | I       |
|   |          |          | **Treatment | amily | (Baseline | nterven |
|   |          | -        | Factors**\  | hi    | at entry  | tion**\ |
|   |          |   Memory | \           | story | into      | \       |
|   |          |          | Radiation   | of    | long-term | Formal  |
|   |          |    (part | in          | lea   | followup, | neur    |
|   |          | icularly | combination | rning | then      | opsycho |
|   |          |          | with:       | or    | per       | logical |
|   |          |  visual, |             | atte  | iodically | eva     |
|   |          |     seq  | -   De      | ntion | as        | luation |
|   |          | uencing, | xamethasone | pro   | c         | to      |
|   |          |          |             | blems | linically | include |
|   |          | temporal | -   TBI     |       | indicated | tests   |
|   |          |          |             |       | for       | of      |
|   |          |  memory) | -   M       |       | patients  | pro     |
|   |          |          | ethotrexate |       | with      | cessing |
|   |          | -   Pr   |     (IT,    |       | evidence  | speed,  |
|   |          | ocessing |     IO,     |       | of        | compute |
|   |          |          |             |       | impaired  | r-based |
|   |          |    speed |   high-dose |       | ed        | att     |
|   |          |          |     IV)     |       | ucational | ention, |
|   |          | -   Visu |             |       | or        | visual  |
|   |          | al-motor | -           |       | v         | motor   |
|   |          |     int  |  Cytarabine |       | ocational | integ   |
|   |          | egration |             |       | progress) | ration, |
|   |          |          |  (high-dose |       |           | memory, |
|   |          | Learning |     IV)     |       |           | compre  |
|   |          | deficits |             |       |           | hension |
|   |          | in math  | Higher      |       |           | of      |
|   |          | and      | radiation   |       |           | verbal  |
|   |          | reading  | dose\       |       |           | instru  |
|   |          | (part    | Larger      |       |           | ctions, |
|   |          | icularly | radiation   |       |           | verbal  |
|   |          | reading  | field\      |       |           | f       |
|   |          | compreh  | Greater     |       |           | luency, |
|   |          | ension)\ | cortical    |       |           | ex      |
|   |          | Di       | volumes\    |       |           | ecutive |
|   |          | minished | Cranial     |       |           | f       |
|   |          | IQ\      | radiation   |       |           | unction |
|   |          | Be       | in          |       |           | and     |
|   |          | havioral | combination |       |           | pl      |
|   |          | change\  | with TBI\   |       |           | anning. |
|   |          | \        | Longer      |       |           | Refer   |
|   |          | **Info   | elapsed     |       |           | p       |
|   |          | Link**:  | time since  |       |           | atients |
|   |          | Neuroc   | therapy     |       |           | with    |
|   |          | ognitive |             |       |           | neuroco |
|   |          | deficits |             |       |           | gnitive |
|   |          | in       |             |       |           | d       |
|   |          | s        |             |       |           | eficits |
|   |          | urvivors |             |       |           | to      |
|   |          | of       |             |       |           | school  |
|   |          | leukemia |             |       |           | liaison |
|   |          | and      |             |       |           | in      |
|   |          | lymphoma |             |       |           | co      |
|   |          | are more |             |       |           | mmunity |
|   |          | fr       |             |       |           | or      |
|   |          | equently |             |       |           | cancer  |
|   |          | related  |             |       |           | center  |
|   |          | to       |             |       |           | (psycho |
|   |          | inf      |             |       |           | logist, |
|   |          | ormation |             |       |           | social  |
|   |          | pr       |             |       |           | worker, |
|   |          | ocessing |             |       |           | school  |
|   |          | (e.g.,   |             |       |           | cou     |
|   |          | learning |             |       |           | nselor) |
|   |          | disa     |             |       |           | to      |
|   |          | bility). |             |       |           | fac     |
|   |          | Neuroc   |             |       |           | ilitate |
|   |          | ognitive |             |       |           | acqu    |
|   |          | deficits |             |       |           | isition |
|   |          | in brain |             |       |           | of      |
|   |          | tumor    |             |       |           | educ    |
|   |          | s        |             |       |           | ational |
|   |          | urvivors |             |       |           | re      |
|   |          | treated  |             |       |           | sources |
|   |          | with     |             |       |           | and/or  |
|   |          | higher   |             |       |           | social  |
|   |          | doses of |             |       |           | skills  |
|   |          | cranial  |             |       |           | tr      |
|   |          | r        |             |       |           | aining. |
|   |          | adiation |             |       |           | C       |
|   |          | are more |             |       |           | onsider |
|   |          | global   |             |       |           | use of  |
|   |          | (sig     |             |       |           | psych   |
|   |          | nificant |             |       |           | otropic |
|   |          | decline  |             |       |           | med     |
|   |          | in IQ).  |             |       |           | ication |
|   |          | Extent   |             |       |           | (e.g.,  |
|   |          | of       |             |       |           | stim    |
|   |          | deficit  |             |       |           | ulants) |
|   |          | depends  |             |       |           | or      |
|   |          | on age   |             |       |           | evidenc |
|   |          | at       |             |       |           | e-based |
|   |          | tr       |             |       |           | rehabil |
|   |          | eatment, |             |       |           | itation |
|   |          | i        |             |       |           | tr      |
|   |          | ntensity |             |       |           | aining. |
|   |          | of       |             |       |           | Ca      |
|   |          | tr       |             |       |           | ution - |
|   |          | eatment, |             |       |           | lower   |
|   |          | and time |             |       |           | s       |
|   |          | since    |             |       |           | tarting |
|   |          | tr       |             |       |           | dose    |
|   |          | eatment. |             |       |           | and     |
|   |          | *Note:   |             |       |           | ass     |
|   |          | New      |             |       |           | essment |
|   |          | deficits |             |       |           | of      |
|   |          | may      |             |       |           | in      |
|   |          | emerge   |             |       |           | creased |
|   |          | over     |             |       |           | sens    |
|   |          | time.*   |             |       |           | itivity |
|   |          |          |             |       |           | when    |
|   |          |          |             |       |           | ini     |
|   |          |          |             |       |           | tiating |
|   |          |          |             |       |           | therapy |
|   |          |          |             |       |           | is      |
|   |          |          |             |       |           | recom   |
|   |          |          |             |       |           | mended. |
|   |          |          |             |       |           | Refer   |
|   |          |          |             |       |           | to      |
|   |          |          |             |       |           | co      |
|   |          |          |             |       |           | mmunity |
|   |          |          |             |       |           | s       |
|   |          |          |             |       |           | ervices |
|   |          |          |             |       |           | for     |
|   |          |          |             |       |           | voc     |
|   |          |          |             |       |           | ational |
|   |          |          |             |       |           | rehabil |
|   |          |          |             |       |           | itation |
|   |          |          |             |       |           | or for  |
|   |          |          |             |       |           | s       |
|   |          |          |             |       |           | ervices |
|   |          |          |             |       |           | for     |
|   |          |          |             |       |           | d       |
|   |          |          |             |       |           | evelopm |
|   |          |          |             |       |           | entally |
|   |          |          |             |       |           | di      |
|   |          |          |             |       |           | sabled. |
+---+----------+----------+-------------+-------+-----------+---------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = CNS\
Score = 1**

+---+-------+-------------+---------------+------+-------+------------+
| * | **T   | **Potential | **Risk        | *    | **Per | **Health   |
| * | herap | Late        | Factors**     | *Hig | iodic | Counseling |
| S | eutic | Effects**   |               | hest | Ev    | Further    |
| e | Agent |             |               | Risk | aluat | Consid     |
| c | (s)** |             |               | F    | ion** | erations** |
| \ |       |             |               | acto |       |            |
| # |       |             |               | rs** |       |            |
| * |       |             |               |      |       |            |
| * |       |             |               |      |       |            |
+===+=======+=============+===============+======+=======+============+
| 4 | *     | **Clinical  | **Host        | **T  | **    | **Cons     |
| 4 | *Cran | leukoenceph | Factors**\    | reat | Histo | iderations |
|   | ial** | alopathy**\ | \             | ment | ry**\ | for        |
|   |       | \           | Younger age   | Fa   | \     | Further    |
|   |       | Spasticity\ | at treatment\ | ctor | **    | Testing    |
|   |       | Ataxia\     | CNS           | s**\ | Cogni | and        |
|   |       | Dysarthria\ | leuke         | \    | tive, | Inter      |
|   |       | Dysphagia\  | mia/lymphoma\ | R    | m     | vention**\ |
|   |       | H           | Relapsed      | adia | otor, | \          |
|   |       | emiparesis\ | leuk          | tion | a     | Brain MRI, |
|   |       | Seizures\   | emia/lymphoma | dose | nd/or | Brain CT   |
|   |       | \           | treated with  | [\   | se    | with MR    |
|   |       | **Info      | CNS-directed  | >]{. | nsory | a          |
|   |       | Link**:     | therapy\      | unde | d     | ngiography |
|   |       | Clinical    | \             | rlin | efici | as         |
|   |       | leukoenc    | **Treatment   | e}24 | ts**\ | clinically |
|   |       | ephalopathy | Factors**\    | Gy\  | \     | indicated; |
|   |       | may present | \             | Frac | **S   | preferred  |
|   |       | with or     | In            | tion | eizur | study      |
|   |       | without     | combination   | dose | es**\ | based on   |
|   |       | imaging     | with:         | [    | \     | in         |
|   |       | ab          |               | \>]{ | **    | tracranial |
|   |       | normalities | -             | .und | Other | lesion to  |
|   |       | (e.g.,      | Dexamethasone | erli | neuro | be         |
|   |       | leukoence   |               | ne}3 | logic | evaluated: |
|   |       | phalopathy, | -             | Gy   | s     |            |
|   |       | cerebral    |  Methotrexate |      | ympto | -   MRI:   |
|   |       | lacunes,    |     (IT, IO,  |      | ms**\ |     White  |
|   |       | cerebral    |     high-dose |      | \     |     matter |
|   |       | atrophy,    |     IV)       |      | (Yea  |            |
|   |       | dystrophic  |               |      | rly)\ | -          |
|   |       | calc        | -             |      | \     |  Gadoliniu |
|   |       | ifications, |    Cytarabine |      | **P   | m-enhanced |
|   |       | m           |               |      | hysic |     MRI:   |
|   |       | ineralizing |    (high-dose |      | al**\ |     Mic    |
|   |       | microa      |     IV)       |      | \     | rovascular |
|   |       | ngiopathy). |               |      | **Spa |     injury |
|   |       | Transient   | Higher        |      | stici |            |
|   |       | white       | radiation     |      | ty**\ | -   CT:    |
|   |       | matter      | dose\         |      | \     |     Calc   |
|   |       | anomalies   | Larger        |      | *     | ifications |
|   |       | may follow  | radiation     |      | *Atax |            |
|   |       | r           | field\        |      | ia**\ | Neurology  |
|   |       | adiotherapy | Greater       |      | \     | co         |
|   |       | and         | cortical      |      | **Dys | nsultation |
|   |       | high-dose   | volumes\      |      | arthr | and        |
|   |       | c           | Longer        |      | ia**\ | follow-up  |
|   |       | hemotherapy | elapsed time  |      | \     | as         |
|   |       | for         | since therapy |      | *     | clinically |
|   |       | medullobla  |               |      | *Hemi | indicated  |
|   |       | stoma/PNET, |               |      | pares |            |
|   |       | may mimic   |               |      | is**\ |            |
|   |       | tumor       |               |      | \     |            |
|   |       | recurrence, |               |      | (Ye   |            |
|   |       | and signify |               |      | arly) |            |
|   |       | risk of     |               |      |       |            |
|   |       | persistent  |               |      |       |            |
|   |       | neurologic  |               |      |       |            |
|   |       | sequelae.   |               |      |       |            |
|   |       | N           |               |      |       |            |
|   |       | euroimaging |               |      |       |            |
|   |       | changes do  |               |      |       |            |
|   |       | not always  |               |      |       |            |
|   |       | correlate   |               |      |       |            |
|   |       | with degree |               |      |       |            |
|   |       | of          |               |      |       |            |
|   |       | cognitive   |               |      |       |            |
|   |       | d           |               |      |       |            |
|   |       | ysfunction. |               |      |       |            |
|   |       | Prospective |               |      |       |            |
|   |       | studies are |               |      |       |            |
|   |       | needed to   |               |      |       |            |
|   |       | define the  |               |      |       |            |
|   |       | dose/effect |               |      |       |            |
|   |       | r           |               |      |       |            |
|   |       | elationship |               |      |       |            |
|   |       | of          |               |      |       |            |
|   |       | neurotoxic  |               |      |       |            |
|   |       | agents.     |               |      |       |            |
|   |       | *Note: New  |               |      |       |            |
|   |       | deficits    |               |      |       |            |
|   |       | may emerge  |               |      |       |            |
|   |       | over time.* |               |      |       |            |
+---+-------+-------------+---------------+------+-------+------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = CNS\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late    **Risk Factors**    **Highest Risk       **Periodic         **Health Counseling
  \#**    Agent(s)**           Effects**                               Factors**            Evaluation**       Further
                                                                                                               Considerations**
  ------- -------------------- ------------------- ------------------- -------------------- ------------------ --------------------
  45      [\>]{.underline}40   **Cerebrovascular   **Host Factors**\   **Treatment          **History**\       **Considerations for
          Gy to:\              complications**\    \                   Factors**\           \                  Further Testing and
          \                    \                   Down syndrome\      \                    **Hemiparesis**\   Intervention**\
          **Cranial\           Stroke\             \                   Radiation dose       \                  \
          Orbital/Eye\         Moyamoya\           **Treatment         [\>]{.underline}55   **Hemiplegia**\    Brain MRI with
          Ear/Infratemporal\   Occlusive cerebral  Factors**\          Gy                   \                  diffusion-weighted
          Nasopharyngeal**     vasculopathy\       \                                        **Weakness**\      imaging with MR
                               \                   Suprasellar                              \                  angiography as
                               **Info Link**:      radiation\                               **Aphasia**\       clinically
                               Moyamoya syndrome   \                                        \                  indicated.
                               is the complete     **Medical                                (Yearly)\          Neurology/
                               occlusion of one or Conditions**\                            \                  neurosurgery
                               more of the three   \                                        **Physical**\      consultation and
                               major cerebral      Sickle cell                              \                  follow-up. Physical
                               vessels with the    disease\                                 **Neurologic       and occupational
                               development of      Neurofibromatosis                        exam**\            therapy as
                               small, immature                                              \                  clinically
                               collateral vessels,                                          (Yearly)           indicated. Note:
                               which reflect an                                                                Revascularization
                               attempt to                                                                      procedures are
                               revascularize the                                                               likely helpful for
                               ischemic portion of                                                             moyamoya. Aspirin
                               the brain.                                                                      prophylaxis has not
                                                                                                               yet been shown to be
                                                                                                               beneficial for
                                                                                                               moyamoya or
                                                                                                               occlusive cerebral
                                                                                                               vasculopathy.

  ---------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Musculoskeletal\
Score = 1**

  ------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late  **Risk        **Highest Risk       **Periodic         **Health Counseling Further Considerations**
  \#**    Agent(s)**           Effects**         Factors**     Factors**            Evaluation**       
  ------- -------------------- ----------------- ------------- -------------------- ------------------ -------------------------------------------------------
  46      **Cranial\           **Craniofacial    **Host        **Host Factors**\    **History**\       **Resources**\
          \                    abnormalities**   Factors**\    \                    \                  \
          Orbital/Eye\                           \             Age \<5 years at     **Psychosocial     FACES - The National Craniofacial Association
          \                                      Younger age   time of treatment\   assessment, with   [www.faces-cranio.org](http://www.faces-cranio.org/)\
          Ear/Infratemporal\                     at treatment\ \                    attention to:**\   \
          \                                      \             **Treatment          \                  **Considerations for Further Testing and
          Nasopharyngeal**                       **Treatment   Factors**\           **Educational      Intervention**\
                                                 Factors**\    \                    and/or vocational  \
                                                 \             Radiation dose       progress**\        Reconstructive craniofacial surgical consultation.
                                                 Higher        [\>]{.underline}30   \                  Consultation with psychologist in patients with
                                                 radiation     Gy                   **Depression**\    adjustment disorders related to facial
                                                 dose                               \                  asymmetry/deformity.
                                                                                    **Anxiety**\       
                                                                                    \                  
                                                                                    **Post-traumatic   
                                                                                    stress**\          
                                                                                    \                  
                                                                                    **Social           
                                                                                    withdrawal**\      
                                                                                    \                  
                                                                                    (Yearly)\          
                                                                                    \                  
                                                                                    **Physical**\      
                                                                                    \                  
                                                                                    **Craniofacial     
                                                                                    abnormalities**\   
                                                                                    \                  
                                                                                    (Yearly)           

  ------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Immune\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential   **Risk Factors**        **Highest   **Periodic        **Health
  \#**    Agent(s)**           Late                                  Risk        Evaluation**      Counseling Further
                               Effects**                             Factors**                     Considerations**
  ------- -------------------- ------------- ----------------------- ----------- ----------------- ------------------
  47      **Cranial\           **Chronic     **Treatment Factors**\              **History**\      **Considerations
          \                    sinusitis**   \                                   \                 for Further
          Orbital/Eye\                       Radiation dose to                   **Rhinorrhea**\   Testing and
          \                                  sinuses                             \                 Intervention**\
          Ear/Infratemporal\                 [\>]{.underline}30 Gy\              **Postnasal       \
          \                                  Radiomimetic                        discharge**\      CT scan of sinuses
          Nasopharyngeal**                   chemotherapy (e.g.,                 \                 as clinically
                                             doxorubicin,                        (Yearly)\         indicated.
                                             dactinomycin)\                      \                 Otolaryngology
                                             \                                   **Physical**\     consultation as
                                             **Medical Conditions**\             \                 clinically
                                             \                                   **Nasal exam**\   indicated
                                             Atopic history\                     \                 
                                             Hypogammaglobulinemia               **Sinuses**\      
                                                                                 \                 
                                                                                 (Yearly)          

  -------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late Effects**                                    **Risk Factors**   **Highest Risk       **Periodic       **Health
  \#**    Agent(s)**                                                                                            Factors**            Evaluation**     Counseling Further
                                                                                                                                                      Considerations**
  ------- -------------------- ------------------------------------------------------------- ------------------ -------------------- ---------------- ------------------
  48      **Cranial\           **Overweight**\                                               **Host Factors**\  **Host Factors**\    **Physical**\    **Health Links**\
          \                    \                                                             \                  \                    \                \
          Orbital/Eye\         Age 2 to 20 years:\                                           Younger at         Age \<4 years old at **Height**\      **See \"Patient
          \                    BMI for age [\>]{.underline}85th to \<95th percentile\        treatment\         time of treatment\   \                Resources\"
          Ear/Infratemporal\   \                                                             \                  Female sex\          **Weight**\      field**\
          \                    Age [\>]{.underline}21 years:\                                **Treatment        \                    \                \
          Nasopharyngeal**     BMI\                                                          Factors**\         **Treatment          **BMI**\         Diet and Physical
                               \                                                             \                  Factors**\           \                Activity\
                               [\>]{.underline}25 to 29.9\                                   Higher cranial     \                    **Blood          \
                               \                                                             radiation dose\    Hypothalamic         pressure**\      **Counseling**\
                               **Obesity**\                                                  Combined with      radiation dose       \                \
                               \                                                             corticosteroids\   [\>]{.underline}20   (Yearly)\        Counsel regarding
                               Age 2 to 20 years:\                                           \                  Gy\                  \                obesity-related
                               BMI for age [\>]{.underline}95th percentile\                  **Medical          \                    **Screening**\   health risks\
                               \                                                             Conditions**\      **Medical            \                \
                               Age [\>]{.underline}21 years:\                                \                  Conditions**\        **Fasting blood  **Considerations
                               BMI ≥ 30\                                                     Familial           \                    glucose**\       for Further
                               \                                                             dyslipidemia\      Inability to         \                Testing and
                               **Info Link**:\                                               Growth hormone     exercise             **Fasting serum  Intervention**\
                               \                                                             deficiency\                             insulin**\       \
                               BMI=wt(kg)/ht(m^2^)\                                          Hypothyroidism                          \                Consider
                               BMI calculator available on-line at:\                                                                 **Fasting lipid  evaluation for
                               <http://nhlbisupport.com/bmi/>\                                                                       profile**\       other co-morbid
                               \                                                                                                     \                conditions
                               Growth charts for patients \<21 years of age available                                                (Every 2 years   including
                               on-line at:\                                                                                          in overweight or dyslipidemia,
                               \                                                                                                     obese patients.  hypertension,
                               [www.cdc.gov/growthcharts](http://www.cdc.gov/growthcharts)                                           Every 5 years in glucose
                                                                                                                                     patients of      intolerance,
                                                                                                                                     normal weight.   diabetes mellitus,
                                                                                                                                     More frequently  hyperinsulinism,
                                                                                                                                     if indicated     and insulin
                                                                                                                                     based on patient resistance.
                                                                                                                                     evaluation.)     Nutritional
                                                                                                                                                      counseling.
                                                                                                                                                      Endocrine
                                                                                                                                                      consultation for
                                                                                                                                                      patients with
                                                                                                                                                      dyslipidemia or
                                                                                                                                                      hyperglycemia.

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 2A**

  -----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late **Risk Factors** **Highest Risk       **Periodic       **Health
  \#**    Agent(s)**           Effects**                         Factors**            Evaluation**     Counseling Further
                                                                                                       Considerations**
  ------- -------------------- ---------------- ---------------- -------------------- ---------------- ------------------
  49      **Cranial\           **Metabolic      **Treatment      **Host Factors**\    **Physical**\    **Health Links**\
          \                    syndrome**\      Factors**\       \                    \                \
          Orbital/Eye\         \                \                Obesity\             **Height**\      **See \"Patient
          \                    **Info Link**:   Surgery in       \                    \                Resources\"
          Ear/Infratemporal\   The metabolic    suprasellar      **Treatment          **Weight**\      field**\
          \                    syndrome is a    region\          Factors**\           \                \
          Nasopharyngeal\      clustering of    Prolonged        \                    **BMI**\         Diet and Physical
          \                    cardiovascular   corticosteroid   Cranial radiation    \                Activity\
          TBI**                risk factors     therapy (e.g.,   dose                 **Blood          \
                               that may further for chronic      [\>]{.underline}18   pressure**\      **Counseling**\
                               increase risk    GVHD)\           Gy                   \                \
                               for              \                                     (Yearly)\        Counsel regarding
                               cardiovascular   **Medical                             \                obesity-related
                               disease.         Conditions**\                         **Screening**\   health risks\
                               Definitions of   \                                     \                \
                               metabolic        Growth hormone                        **Fasting blood  **Considerations
                               syndrome are     deficiency\                           glucose**\       for Further
                               evolving, but    Hypogonadism                          \                Testing and
                               generally                                              **Fasting serum  Intervention**\
                               include a                                              insulin**\       \
                               combination of                                         \                Consider endocrine
                               obesity with                                           **Fasting lipid  consult if insulin
                               insulin                                                profile**\       resistance/
                               resistance,                                            \                metabolic syndrome
                               dyslipidemia,                                          (Every 5 years.  is suspected.
                               and elevated                                           More frequently  Nutritional
                               blood pressure.                                        if indicated     counseling.
                               *Note: Patients                                        based on patient Cardiology
                               who received TBI                                       evaluation.)     consultation as
                               may develop                                                             clinically
                               features of                                                             indicated.
                               metabolic                                                               
                               syndrome without                                                        
                               associated                                                              
                               obesity.*                                                               

  -----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Neuroendocrine Axis**

**System = Endocrine/Metabolic\
Score = 1**

+---+-----------+---------------+-------+-------+-------+--------------+
| * | **Th      | **Potential   | *     | **Hi  | **Per | **Health     |
| * | erapeutic | Late          | *Risk | ghest | iodic | Counseling   |
| S | A         | Effects**     | Fact  | Risk  | Ev    | Further      |
| e | gent(s)** |               | ors** | Fact  | aluat | Cons         |
| c |           |               |       | ors** | ion** | iderations** |
| \ |           |               |       |       |       |              |
| # |           |               |       |       |       |              |
| * |           |               |       |       |       |              |
| * |           |               |       |       |       |              |
+===+===========+===============+=======+=======+=======+==============+
| 5 | *         | **Growth      | *     | *     | **    | **Health     |
| 0 | *Cranial\ | hormone       | *Host | *Trea | Histo | Links**\     |
|   | \         | deficiency**\ | Facto | tment | ry**\ | \            |
|   | Orb       | \             | rs**\ | Facto | \     | **See        |
|   | ital/Eye\ | **Info        | \     | rs**\ | **    | \"Patient    |
|   | \         | Link**:       | Yo    | \     | Asses | Resources\"  |
|   | Ear/Infra | Growth charts | unger | Radi  | sment | field**\     |
|   | temporal\ | available     | at    | ation | of    | \            |
|   | \         | on-line at:\  | treat | dose  | n     | Growth       |
|   | Nasoph    | [www.cd       | ment\ | [\>   | utrit | Hormone      |
|   | aryngeal\ | c.gov/growthc | \     | ]{.un | ional | Deficiency\  |
|   | \         | harts](http:/ | *     | derli | stat  | See also:    |
|   | TBI**     | /www.cdc.gov/ | *Trea | ne}18 | us**\ | Hypo         |
|   |           | growthcharts) | tment | Gy\   | \     | pituitarism\ |
|   |           |               | Facto | Pre   | (     | \            |
|   |           |               | rs**\ | trans | Every | **           |
|   |           |               | \     | plant | six   | Resources**\ |
|   |           |               | H     | cr    | m     | \            |
|   |           |               | igher | anial | onths | [www.magicf  |
|   |           |               | radi  | radia | until | oundation.or |
|   |           |               | ation | tion\ | g     | g](http://ww |
|   |           |               | d     | TBI   | rowth | w.magicfound |
|   |           |               | oses\ | given | is    | ation.org/)\ |
|   |           |               | Su    | in    | compl | \            |
|   |           |               | rgery | s     | eted, | **Co         |
|   |           |               | in    | ingle | then  | nsiderations |
|   |           |               | s     | fra   | yea   | for Further  |
|   |           |               | upras | ction | rly)\ | Testing and  |
|   |           |               | ellar |       | \     | Int          |
|   |           |               | re    |       | **P   | ervention**\ |
|   |           |               | gion\ |       | hysic | \            |
|   |           |               | Pre   |       | al**\ | Obtain x-ray |
|   |           |               | trans |       | \     | for bone age |
|   |           |               | plant |       | *     | in poorly    |
|   |           |               | radia |       | *Heig | growing      |
|   |           |               | tion\ |       | ht**\ | children.    |
|   |           |               | TBI   |       | \     | Endocrine    |
|   |           |               | [\>   |       | *     | consultation |
|   |           |               | ]{.un |       | *Weig | for:         |
|   |           |               | derli |       | ht**\ |              |
|   |           |               | ne}10 |       | \     | -   Height   |
|   |           |               | Gy in |       | **B   |     below    |
|   |           |               | s     |       | MI**\ |     3rd      |
|   |           |               | ingle |       | \     |              |
|   |           |               | frac  |       | (     |   percentile |
|   |           |               | tion\ |       | Every |     on       |
|   |           |               | TBI   |       | six   |     growth   |
|   |           |               | [\>   |       | m     |     chart    |
|   |           |               | ]{.un |       | onths |              |
|   |           |               | derli |       | until | -   Drop     |
|   |           |               | ne}12 |       | g     |     [\>]{    |
|   |           |               | Gy    |       | rowth | .underline}2 |
|   |           |               | fr    |       | is    |              |
|   |           |               | actio |       | compl |   percentile |
|   |           |               | nated |       | eted, |     rankings |
|   |           |               |       |       | then  |     on       |
|   |           |               |       |       | yea   |     growth   |
|   |           |               |       |       | rly)\ |     chart    |
|   |           |               |       |       | \     |              |
|   |           |               |       |       | **T   | -   Growth   |
|   |           |               |       |       | anner |     velocity |
|   |           |               |       |       | stagi |     \<4 to 5 |
|   |           |               |       |       | ng**\ |     cm/year  |
|   |           |               |       |       | \     |     during   |
|   |           |               |       |       | (     |              |
|   |           |               |       |       | Every |    childhood |
|   |           |               |       |       | six   |              |
|   |           |               |       |       | m     | -   Lack of  |
|   |           |               |       |       | onths |     pubertal |
|   |           |               |       |       | until |     growth   |
|   |           |               |       |       | sex   |     spurt    |
|   |           |               |       |       | ually |              |
|   |           |               |       |       | ma    | Evaluate     |
|   |           |               |       |       | ture) | thyroid      |
|   |           |               |       |       |       | function in  |
|   |           |               |       |       |       | any poorly   |
|   |           |               |       |       |       | growing      |
|   |           |               |       |       |       | child.       |
|   |           |               |       |       |       | Consult with |
|   |           |               |       |       |       | end          |
|   |           |               |       |       |       | ocrinologist |
|   |           |               |       |       |       | regarding    |
|   |           |               |       |       |       | ri           |
|   |           |               |       |       |       | sks/benefits |
|   |           |               |       |       |       | of adult     |
|   |           |               |       |       |       | growth       |
|   |           |               |       |       |       | hormone      |
|   |           |               |       |       |       | replacement  |
|   |           |               |       |       |       | therapy.     |
|   |           |               |       |       |       | Consider     |
|   |           |               |       |       |       | bone density |
|   |           |               |       |       |       | testing in   |
|   |           |               |       |       |       | patients who |
|   |           |               |       |       |       | are growth   |
|   |           |               |       |       |       | hormone      |
|   |           |               |       |       |       | deficient.   |
+---+-----------+---------------+-------+-------+-------+--------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential    **Risk Factors**     **Highest   **Periodic         **Health Counseling Further Considerations**
  \#**    Agent(s)**           Late Effects**                      Risk        Evaluation**       
                                                                   Factors**                      
  ------- -------------------- -------------- -------------------- ----------- ------------------ -------------------------------------------------------------
  51      **Cranial\           **Precocious   **Host Factors**\                **Physical**\      **Health Links**\
          \                    puberty**      \                                \                  \
          Orbital/Eye\                        Female sex\                      **Height**\        **See \"Patient Resources\" field**\
          \                                   Younger age at                   \                  \
          Ear/Infratemporal\                  treatment\                       **Weight**\        Precocious Puberty\
          \                                   \                                \                  \
          Nasopharyngeal**                    **Treatment                      **Tanner stage**\  **Resources**\
                                              Factors**\                       \                  \
                                              \                                **Testicular       [www.magicfoundation.org](http://www.magicfoundation.org/)\
                                              Radiation doses                  volume by Prader   \
                                              [\>]{.underline}18               orchidometry       **Considerations for Further Testing and Intervention**\
                                              Gy                               (males only)**\    \
                                                                               \                  Obtain x-ray for bone age in rapidly growing children.
                                                                               (Yearly until      Endocrine consultation for accelerated puberty (puberty in
                                                                               sexually mature)\  girl \<8 years old or boy \<9 years old).
                                                                               \                  
                                                                               **Screening**\     
                                                                               \                  
                                                                               **FSH**\           
                                                                               \                  
                                                                               **LH**\            
                                                                               \                  
                                                                               **Testosterone**   
                                                                               (males only)\      
                                                                               \                  
                                                                               **Estradiol**      
                                                                               (females only)\    
                                                                               \                  
                                                                               (As clinically     
                                                                               indicated in       
                                                                               patients with      
                                                                               signs of           
                                                                               accelerated        
                                                                               pubertal           
                                                                               progression and    
                                                                               growth)            

  -------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late         **Risk         **Highest Risk       **Periodic          **Health Counseling Further Considerations**
  \#**    Agent(s)**           Effects**                Factors**      Factors**            Evaluation**        
  ------- -------------------- ------------------------ -------------- -------------------- ------------------- -------------------------------------------------------------
  52      [\>]{.underline}40   **Hyperprolactinemia**   **Treatment    **Treatment          **History**\        **Health Links**\
          Gy to:\                                       Factors**\     Factors**\           \                   \
          \                                             \              \                    **Galactorrhea**\   **See \"Patient Resources\" field**\
          **Cranial\                                    Higher         Radiation dose       \                   \
          \                                             radiation      [\>]{.underline}50   **Decreased libido  Hyperprolactinemia\
          Orbital/Eye\                                  dose\          Gy                   (males)**\          \
          \                                             Surgery or                          \                   **Resources**\
          Ear/Infratemporal\                            tumor in                            **Menstrual history \
          \                                             hypothalamic                        (females)**\        [www.magicfoundation.org](http://www.magicfoundation.org/)\
          Nasopharyngeal**                              area                                \                   \
                                                                                            (Yearly)\           **Considerations for Further Testing and Intervention**\
                                                                                            \                   \
                                                                                            **Screening**\      CT evaluation of sella turcica for pituitary adenoma in
                                                                                            \                   patients with hyperprolactinemia. Endocrine consultation for
                                                                                            **Prolactin         patients with hyperprolactinemia or galactorrhea (or
                                                                                            level**\            amenorrhea in females).
                                                                                            \                   
                                                                                            (Males with         
                                                                                            galactorrhea or     
                                                                                            decreased libido;   
                                                                                            Females with        
                                                                                            galactorrhea or     
                                                                                            amenorrhea)         

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late      **Risk        **Highest   **Periodic          **Health
  \#**    Agent(s)**           Effects**             Factors**     Risk        Evaluation**        Counseling Further
                                                                   Factors**                       Considerations**
  ------- -------------------- --------------------- ------------- ----------- ------------------- ------------------
  53      [\>]{.underline}40   **Central             **Treatment               **History**\        **Health Links**\
          Gy to:\              hypothyroidism**\     Factors**\                \                   \
          \                    \                     \                         **Fatigue**\        **See \"Patient
          **Cranial\           **Info Link**:        Higher                    \                   Resources\"
          \                    Central               radiation                 **Weight gain**\    field**\
          Orbital/Eye\         hypothyroidism        dose                      \                   \
          \                    includes                                        **Cold              Thyroid Problems\
          Ear/Infratemporal\   thyroid-releasing and                           intolerance**\      See also:
          \                    thyroid-stimulating                             \                   Hypopituitarism\
          Nasopharyngeal**     hormone deficiency                              **Constipation**\   \
                                                                               \                   **Counseling**\
                                                                               **Dry skin**\       \
                                                                               \                   Counsel at-risk
                                                                               **Brittle hair**\   females of
                                                                               \                   childbearing
                                                                               **Depressed mood**\ potential to have
                                                                               \                   their thyroid
                                                                               (Yearly; Consider   levels checked
                                                                               more frequent       prior to
                                                                               screening during    attempting
                                                                               periods of rapid    pregnancy and
                                                                               growth)\            periodically
                                                                               \                   throughout
                                                                               **Physical**\       pregnancy.\
                                                                               \                   \
                                                                               **Height**\         **Considerations
                                                                               \                   for Further
                                                                               **Weight**\         Testing and
                                                                               \                   Intervention**\
                                                                               **Hair**\           \
                                                                               \                   Consider TSH surge
                                                                               **Skin**\           testing. Endocrine
                                                                               \                   consultation for
                                                                               **Thyroid exam**\   thyroid hormone
                                                                               \                   replacement.
                                                                               (Yearly; Consider   
                                                                               more frequent       
                                                                               screening during    
                                                                               periods of rapid    
                                                                               growth)\            
                                                                               \                   
                                                                               **Screening**\      
                                                                               \                   
                                                                               **TSH**\            
                                                                               \                   
                                                                               **Free T4**\        
                                                                               \                   
                                                                               (Yearly; Consider   
                                                                               more frequent       
                                                                               screening during    
                                                                               periods of rapid    
                                                                               growth)             

  -------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Male Reproductive/Female Reproductive\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late **Risk        **Highest   **Periodic Evaluation**         **Health Counseling Further Considerations**
  \#**    Agent(s)**           Effects**        Factors**     Risk                                        
                                                              Factors**                                   
  ------- -------------------- ---------------- ------------- ----------- ------------------------------- -----------------------------------------------------
  54      [\>]{.underline}40   **Gonadotropin   **Treatment               ***[MALES]{.underline}***:\     ***[MALES]{.underline}***:\
          Gy to:\              deficiency**\    Factors**\                \                               \
          \                    \                \                         **History**\                    **Health Links**\
          **Cranial\           **Info Link**:   Higher                    \                               \
          \                    Gonadotropin     radiation                 **Pubertal (onset, tempo)**\    **See \"Patient Resources\" field**\
          Orbital/Eye\         deficiency       dose                      \                               \
          \                    includes LH and                            **Sexual function (erections,   Male Health Issues\
          Ear/Infratemporal\   FSH deficiency.                            nocturnal emissions, libido)**\ See also: Hypopituitarism\
          \                                                               \                               \
          Nasopharyngeal**                                                **Medication use impacting      **Resources**\
                                                                          sexual function**\              \
                                                                          \                               American Society for Reproductive Medicine:
                                                                          (Yearly)\                       [www.asrm.org](http://www.asrm.org/)\
                                                                          \                               Fertile Hope:
                                                                          **Physical**\                   [www.fertilehope.org](http://www.fertilehope.org/)\
                                                                          \                               \
                                                                          **Tanner stage**\               **Considerations for Further Testing and
                                                                          \                               Intervention**\
                                                                          **Testicular volume by Prader   \
                                                                          orchidometry**\                 Refer to endocrinologist for delayed puberty or
                                                                          \                               persistently abnormal hormone levels. Hormonal
                                                                          (Yearly until sexually mature)\ replacement therapy for hypogonadal patients.
                                                                          \                               Reproductive endocrinology referral for infertility
                                                                          **Screening**\                  evaluation and consultation regarding assisted
                                                                          \                               reproductive technologies. Consider bone density
                                                                          **FSH**\                        testing in patients who are gonadotropin deficient.
                                                                          \                               
                                                                          **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)  

                                                                          ***[FEMALES]{.underline}***:\   ***[FEMALES]{.underline}***:\
                                                                          \                               \
                                                                          **History**\                    **Health Links**\
                                                                          \                               \
                                                                          **Pubertal (onset, tempo)**\    **See \"Patient Resources\" field**\
                                                                          \                               \
                                                                          **Menstrual/pregnancy           Female Health Issues\
                                                                          history**\                      See also: Hypopituitarism\
                                                                          \                               \
                                                                          **Sexual function (vaginal      **Resources**\
                                                                          dryness, libido)**\             \
                                                                          \                               American Society for Reproductive Medicine:
                                                                          **Medication use impacting      [www.asrm.org](http://www.asrm.org/)\
                                                                          sexual function**\              Fertile Hope:
                                                                          \                               [www.fertilehope.org](http://www.fertilehope.org/)\
                                                                          (Yearly)\                       \
                                                                          \                               **Considerations for Further Testing and
                                                                          **Physical**\                   Intervention**\
                                                                          \                               \
                                                                          **Tanner stage**\               Refer to endocrinologist for delayed puberty or
                                                                          \                               persistently abnormal hormone levels. Hormonal
                                                                          (Yearly until sexually mature)\ replacement therapy for hypogonadal patients.
                                                                          \                               Reproductive endocrinology referral for infertility
                                                                          **Screening**\                  evaluation and consultation regarding assisted
                                                                          \                               reproductive technologies. Consider bone density
                                                                          **FSH**\                        testing in patients who are gonadotropin deficient.
                                                                          \                               
                                                                          **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)            
  -------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late  **Risk        **Highest Risk Factors** **Periodic          **Health Counseling Further Considerations**
  \#**    Agent(s)**           Effects**         Factors**                              Evaluation**        
  ------- -------------------- ----------------- ------------- ------------------------ ------------------- -------------------------------------------------------------
  55      [\>]{.underline}40   **Central adrenal **Treatment   **Treatment Factors**\   **History**\        **Health Links**\
          Gy to:\              insufficiency**   Factors**\    \                        \                   \
          \                                      \             Prior development of     **Failure to        **See \"Patient Resources\" field**\
          **Cranial\                             Higher        another                  thrive**\           \
          \                                      radiation     hypothalamic-pituitary   \                   Central Adrenal Insufficiency\
          Orbital/Eye\                           dose\         endocrinopathy           **Anorexia**\       See also: Hypopituitarism\
          \                                      Surgery or                             \                   \
          Ear/Infratemporal\                     tumor in the                           **Dehydration**\    **Resources**\
          \                                      suprasellar                            \                   \
          Nasopharyngeal**                       region                                 **Hypoglycemia**\   [www.magicfoundation.org](http://www.magicfoundation.org/)\
                                                                                        \                   \
                                                                                        **Lethargy**\       **Counseling**\
                                                                                        \                   \
                                                                                        **Unexplained       Counsel regarding corticosteroid replacement therapy and
                                                                                        hypotension**\      stress dosing. Counsel regarding Medical Alert bracelet.\
                                                                                        \                   \
                                                                                        (Yearly)\           **Considerations for Further Testing and Intervention**\
                                                                                        \                   \
                                                                                        **Screening**\      Endocrine consultation for further evaluation and replacement
                                                                                        \                   steroids
                                                                                        **8:00 a.m. serum   
                                                                                        cortisol**\         
                                                                                        \                   
                                                                                        (Yearly for at      
                                                                                        least 15 years      
                                                                                        after treatment and 
                                                                                        as clinically       
                                                                                        indicated)          

  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Eye**

**System = Ocular\
Score = 1**

+---+---------+------+---------------+-----------+----------+---------+
| * | **Ther  | **P  | **Risk        | **Highest | **       | *       |
| * | apeutic | oten | Factors**     | Risk      | Periodic | *Health |
| S | Age     | tial |               | Factors** | Eval     | Cou     |
| e | nt(s)** | Late |               |           | uation** | nseling |
| c |         | E    |               |           |          | Further |
| \ |         | ffec |               |           |          | Co      |
| # |         | ts** |               |           |          | nsidera |
| * |         |      |               |           |          | tions** |
| * |         |      |               |           |          |         |
+===+=========+======+===============+===========+==========+=========+
| 5 | **C     | *    | **Treatment   | **        | **Hi     | *       |
| 6 | ranial\ | *Cat | Factors**\    | Treatment | story**\ | *Health |
|   | \       | arac | \             | F         | \        | L       |
|   | Orbit   | ts** | Radiation     | actors**\ | **Visual | inks**\ |
|   | al/Eye\ |      | dose          | \         | changes  | \       |
|   | \       |      | [\>]{         | Radiation | (d       | **See   |
|   | TBI**\  |      | .underline}10 | dose      | ecreased | \"      |
|   | \       |      | Gy\           | [\>]{.und | acuity,  | Patient |
|   | **Info  |      | TBI           | erline}15 | halos,   | Reso    |
|   | Link**: |      | [\>]          | Gy\       | dipl     | urces\" |
|   | Rad     |      | {.underline}2 | Fraction  | opia)**\ | f       |
|   | iation- |      | Gy in single  | dose      | \        | ield**\ |
|   | related |      | fraction\     | [\>]{.un  | (        | \       |
|   | ocular  |      | TBI           | derline}2 | Yearly)\ | Cat     |
|   | compli  |      | [\>]          | Gy\       | \        | aracts\ |
|   | cations |      | {.underline}5 | TBI       | **Phy    | \       |
|   | other   |      | Gy            | [\>]{.un  | sical**\ | **      |
|   | than    |      | fractionated\ | derline}5 | \        | Conside |
|   | ca      |      | Radiation     | Gy in     | **Visual | rations |
|   | taracts |      | combined      | single    | a        | for     |
|   | are     |      | with:         | fraction\ | cuity**\ | Further |
|   | ge      |      |               | TBI       | \        | Testing |
|   | nerally |      | -   Co        | [\>]{.und | **Fun    | and     |
|   | ass     |      | rticosteroids | erline}10 | duscopic | I       |
|   | ociated |      |               | Gy        | exam to  | nterven |
|   | only    |      | -   Busulfan  | frac      | evaluate | tion**\ |
|   | with    |      |               | tionated\ | for lens | \       |
|   | orbi    |      | -   Longer    | C         | op       | Ongoing |
|   | tal/eye |      |     interval  | ranial/or | acity**\ | ophtha  |
|   | ra      |      |     since     | bital/eye | \        | lmology |
|   | diation |      |     treatment | radiation | (        | fo      |
|   | or      |      |               | combined  | Yearly)\ | llow-up |
|   | higher  |      |               | with TBI  | \        | for     |
|   | dose    |      |               |           | **Scre   | ide     |
|   | cranial |      |               |           | ening**\ | ntified |
|   | rad     |      |               |           | \        | pr      |
|   | iation. |      |               |           | **Ev     | oblems. |
|   | H       |      |               |           | aluation | Refer   |
|   | owever, |      |               |           | by       | p       |
|   | p       |      |               |           | op       | atients |
|   | atients |      |               |           | hthalmol | with    |
|   | with a  |      |               |           | ogist**\ | visual  |
|   | history |      |               |           | \        | d       |
|   | of an   |      |               |           | (Yearly  | eficits |
|   | ocular  |      |               |           | for      | to      |
|   | tumor   |      |               |           | patients | school  |
|   | (e.g.,  |      |               |           | with     | liaison |
|   | r       |      |               |           | ocular   | in      |
|   | etinobl |      |               |           | tumors   | co      |
|   | astoma) |      |               |           | \[re     | mmunity |
|   | are at  |      |               |           | gardless | or      |
|   | higher  |      |               |           | of       | cancer  |
|   | risk    |      |               |           | r        | center  |
|   | for     |      |               |           | adiation | (psycho |
|   | lat     |      |               |           | dose\]   | logist, |
|   | e-onset |      |               |           | and for  | social  |
|   | ocular  |      |               |           | those    | worker, |
|   | compli  |      |               |           | who      | school  |
|   | cations |      |               |           | received | cou     |
|   | and     |      |               |           | TBI or   | nselor) |
|   | should  |      |               |           | [\       | to      |
|   | receive |      |               |           | >]{.unde | fac     |
|   | ongoing |      |               |           | rline}30 | ilitate |
|   | fo      |      |               |           | Gy       | acqu    |
|   | llow-up |      |               |           | cra      | isition |
|   | by an   |      |               |           | nial/orb | of      |
|   | o       |      |               |           | ital/eye | educ    |
|   | phthalm |      |               |           | ra       | ational |
|   | ologist |      |               |           | diation. | res     |
|   | at      |      |               |           | Every 3  | ources. |
|   | least   |      |               |           | years    |         |
|   | an      |      |               |           | for      |         |
|   | nually, |      |               |           | patients |         |
|   | and     |      |               |           | without  |         |
|   | more    |      |               |           | ocular   |         |
|   | fre     |      |               |           | tumors   |         |
|   | quently |      |               |           | who      |         |
|   | if      |      |               |           | received |         |
|   | cli     |      |               |           | \<30     |         |
|   | nically |      |               |           | Gy.)     |         |
|   | ind     |      |               |           |          |         |
|   | icated. |      |               |           |          |         |
+---+---------+------+---------------+-----------+----------+---------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Ocular\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late        **Risk          **Highest Risk      **Periodic           **Health Counseling Further Considerations**
  \#**    Agent(s)**           Effects**               Factors**       Factors**           Evaluation**         
  ------- -------------------- ----------------------- --------------- ------------------- -------------------- -------------------------------------------------------
  57      [\>]{.underline}30   **Ocular toxicity**\    **Treatment     **Host Factors**\   **History**\         **Health Links**\
          Gy to:\              \                       Factors**\      \                   \                    \
          \                    Orbital hypoplasia\     \               Chronic GVHD        **Visual changes     **See \"Patient Resources\" field**\
          **Cranial\           Lacrimal duct atrophy\  Higher          (xerophthalmia      (decreased acuity,   \
          \                    Xerophthalmia           radiation dose\ only)\              halos, diplopia)**\  Eye Health\
          Orbital/Eye**\       (keratoconjunctivitis   Higher daily    \                   \                    \
          \                    sicca)\                 fraction dose\  **Treatment         **Dry eye**\         **Resources**\
          **Info Link**:       Keratitis\              Radiomimetic    Factors**\          \                    \
          Radiation-related    Telangiectasias\        chemotherapy    \                   **Persistent eye     FACES - The National Craniofacial Association website:
          ocular complications Retinopathy\            (e.g.,          Fraction dose       irritation**\        [www.faces-cranio.org](http://www.faces-cranio.org/)\
          other than cataracts Optic chiasm            doxorubicin,    [\>]{.underline}2   \                    \
          are generally        neuropathy\             dactinomycin)   Gy                  **Excessive          **Considerations for Further Testing and
          associated only with Enophthalmos\           \[problems                          tearing**\           Intervention**\
          orbital/eye          Chronic painful eye\    related to                          \                    \
          radiation or higher  Maculopathy\            tearing\]                           **Light              Consider every six month ophthalmology evaluation for
          dose cranial         Papillopathy\                                               sensitivity**\       patients with corneal damage (usually associated with
          radiation. However,  Glaucoma\                                                   \                    xerophthalmia) or complex ocular problems. Refer
          patients with a      \                                                           **Poor night         patients with visual deficits to school liaison in
          history of an ocular **Info Link**: Reduced                                      vision**\            community or cancer center (psychologist, social
          tumor (e.g.,         visual acuity may be                                        \                    worker, school counselor) to facilitate acquisition of
          retinoblastoma) are  associated with                                             **Painful eye**\     educational resources.
          at higher risk for   cataracts, retinal                                          \                    
          late-onset ocular    damage, and optic nerve                                     (Yearly)\            
          complications and    damage.                                                     \                    
          should receive                                                                   **Physical**\        
          ongoing follow-up by                                                             \                    
          an ophthalmologist                                                               **Visual acuity**\   
          at least annually,                                                               \                    
          and more frequently                                                              **Funduscopic        
          if clinically                                                                    exam**\              
          indicated.                                                                       \                    
                                                                                           (Yearly)\            
                                                                                           \                    
                                                                                           **Screening**\       
                                                                                           \                    
                                                                                           **Evaluation by      
                                                                                           ophthalmologist**\   
                                                                                           \                    
                                                                                           (Yearly)             

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Ear**

**System = Auditory\
Score = 1**

+---+-----------+---------+-------+---------------+---------+---------+
| * | **Th      | **Po    | *     | **Highest     | **P     | *       |
| * | erapeutic | tential | *Risk | Risk          | eriodic | *Health |
| S | A         | Late    | Fact  | Factors**     | Evalu   | Cou     |
| e | gent(s)** | Ef      | ors** |               | ation** | nseling |
| c |           | fects** |       |               |         | Further |
| \ |           |         |       |               |         | Co      |
| # |           |         |       |               |         | nsidera |
| * |           |         |       |               |         | tions** |
| * |           |         |       |               |         |         |
+===+===========+=========+=======+===============+=========+=========+
| 5 | [\>]{.und | **      | *     | **Treatment   | **His   | *       |
| 8 | erline}30 | Ototoxi | *Host | Factors**\    | tory**\ | *Health |
|   | Gy to:\   | city**\ | Facto | \             | \       | L       |
|   | \         | \       | rs**\ | Dose          | **      | inks**\ |
|   | *         | Tym     | \     | [\>]{         | Hearing | \       |
|   | *Cranial\ | panoscl | Yo    | .underline}50 | diffi   | **See   |
|   | \         | erosis\ | unger | Gy            | culties | \"      |
|   | Ear/Infra | Otoscl  | age   |               | (with/  | Patient |
|   | temporal\ | erosis\ | at    |               | without | Reso    |
|   | \         | Eus     | treat |               | bac     | urces\" |
|   | Nasopha   | tachian | ment\ |               | kground | f       |
|   | ryngeal** | tube    | \     |               | no      | ield**\ |
|   |           | dysfu   | *     |               | ise)**\ | \       |
|   |           | nction\ | *Trea |               | \       | Hearing |
|   |           | Con     | tment |               | **Tinn  | Loss\   |
|   |           | ductive | Facto |               | itus**\ | \       |
|   |           | hearing | rs**\ |               | \       | Educ    |
|   |           | loss    | \     |               | **Ver   | ational |
|   |           |         | H     |               | tigo**\ | Issues\ |
|   |           |         | igher |               | \       | \       |
|   |           |         | radi  |               | (Y      | **      |
|   |           |         | ation |               | early)\ | Conside |
|   |           |         | dose\ |               | \       | rations |
|   |           |         | \     |               | **Phys  | for     |
|   |           |         | **Me  |               | ical**\ | Further |
|   |           |         | dical |               | \       | Testing |
|   |           |         | Con   |               | **Ot    | and     |
|   |           |         | ditio |               | oscopic | I       |
|   |           |         | ns**\ |               | exam**\ | nterven |
|   |           |         | \     |               | \       | tion**\ |
|   |           |         | Ch    |               | (Y      | \       |
|   |           |         | ronic |               | early)\ | Au      |
|   |           |         | ot    |               | \       | diology |
|   |           |         | itis\ |               | **Scree | consu   |
|   |           |         | Ch    |               | ning**\ | ltation |
|   |           |         | ronic |               | \       | for     |
|   |           |         | ce    |               | **C     | p       |
|   |           |         | rumen |               | omplete | atients |
|   |           |         | impa  |               | pure    | with    |
|   |           |         | ction |               | tone    | prog    |
|   |           |         |       |               | au      | ressive |
|   |           |         |       |               | diogram | hearing |
|   |           |         |       |               | or      | loss.   |
|   |           |         |       |               | br      | Otolary |
|   |           |         |       |               | ainstem | ngology |
|   |           |         |       |               | a       | consu   |
|   |           |         |       |               | uditory | ltation |
|   |           |         |       |               | evoked  | for     |
|   |           |         |       |               | r       | p       |
|   |           |         |       |               | esponse | atients |
|   |           |         |       |               | (BAER,  | with    |
|   |           |         |       |               | ABR)**\ | chronic |
|   |           |         |       |               | \       | inf     |
|   |           |         |       |               | (Yearly | ection, |
|   |           |         |       |               | after   | cerumen |
|   |           |         |       |               | com     | imp     |
|   |           |         |       |               | pletion | action, |
|   |           |         |       |               | of      | or      |
|   |           |         |       |               | therapy | other   |
|   |           |         |       |               | for 5   | ana     |
|   |           |         |       |               | years   | tomical |
|   |           |         |       |               | \[for   | p       |
|   |           |         |       |               | p       | roblems |
|   |           |         |       |               | atients | exace   |
|   |           |         |       |               | \<10    | rbating |
|   |           |         |       |               | years   | or      |
|   |           |         |       |               | old,    | contr   |
|   |           |         |       |               | c       | ibuting |
|   |           |         |       |               | ontinue | to      |
|   |           |         |       |               | yearly  | hearing |
|   |           |         |       |               | until   | loss.   |
|   |           |         |       |               | age     | Speech  |
|   |           |         |       |               | 10\],   | and     |
|   |           |         |       |               | then    | l       |
|   |           |         |       |               | every 5 | anguage |
|   |           |         |       |               | years.  | therapy |
|   |           |         |       |               | If      | for     |
|   |           |         |       |               | hearing | c       |
|   |           |         |       |               | loss is | hildren |
|   |           |         |       |               | de      | with    |
|   |           |         |       |               | tected, | hearing |
|   |           |         |       |               | test at | loss.   |
|   |           |         |       |               | least   | Refer   |
|   |           |         |       |               | yearly  | p       |
|   |           |         |       |               | or as   | atients |
|   |           |         |       |               | reco    | with    |
|   |           |         |       |               | mmended | a       |
|   |           |         |       |               | by      | uditory |
|   |           |         |       |               | audio   | d       |
|   |           |         |       |               | logist. | eficits |
|   |           |         |       |               | If      | to      |
|   |           |         |       |               | c       | school  |
|   |           |         |       |               | linical | liaison |
|   |           |         |       |               | su      | in      |
|   |           |         |       |               | spicion | co      |
|   |           |         |       |               | of      | mmunity |
|   |           |         |       |               | hearing | or      |
|   |           |         |       |               | loss at | cancer  |
|   |           |         |       |               | any     | center  |
|   |           |         |       |               | time,   | (psycho |
|   |           |         |       |               | test as | logist, |
|   |           |         |       |               | cli     | social  |
|   |           |         |       |               | nically | worker, |
|   |           |         |       |               | ind     | school  |
|   |           |         |       |               | icated. | cou     |
|   |           |         |       |               | If      | nselor) |
|   |           |         |       |               | au      | to      |
|   |           |         |       |               | diogram | fac     |
|   |           |         |       |               | is      | ilitate |
|   |           |         |       |               | incon   | pr      |
|   |           |         |       |               | clusive | ovision |
|   |           |         |       |               | or      | of      |
|   |           |         |       |               | uneva   | educ    |
|   |           |         |       |               | luable, | ational |
|   |           |         |       |               | refer   | res     |
|   |           |         |       |               | to      | ources. |
|   |           |         |       |               | audi    | C       |
|   |           |         |       |               | ologist | onsider |
|   |           |         |       |               | for     | spec    |
|   |           |         |       |               | consid  | ialized |
|   |           |         |       |               | eration | eva     |
|   |           |         |       |               | of      | luation |
|   |           |         |       |               | elec    | for     |
|   |           |         |       |               | trophys | s       |
|   |           |         |       |               | iologic | pecific |
|   |           |         |       |               | testing | needs   |
|   |           |         |       |               | e.g.,   | and/or  |
|   |           |         |       |               | OAEs.)\ | prefe   |
|   |           |         |       |               | \       | rential |
|   |           |         |       |               | **Info  | cl      |
|   |           |         |       |               | L       | assroom |
|   |           |         |       |               | ink**:\ | s       |
|   |           |         |       |               | \       | eating, |
|   |           |         |       |               | C       | FM      |
|   |           |         |       |               | omplete | amplif  |
|   |           |         |       |               | pure    | ication |
|   |           |         |       |               | tone    | system, |
|   |           |         |       |               | au      | and     |
|   |           |         |       |               | diogram | other   |
|   |           |         |       |               | should  | educ    |
|   |           |         |       |               | include | ational |
|   |           |         |       |               | testing | ass     |
|   |           |         |       |               | of both | istance |
|   |           |         |       |               | ears:   | as      |
|   |           |         |       |               |         | ind     |
|   |           |         |       |               | 1.  Air | icated. |
|   |           |         |       |               |     con |         |
|   |           |         |       |               | duction |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               |    from |         |
|   |           |         |       |               |     250 |         |
|   |           |         |       |               |     to  |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               |    8000 |         |
|   |           |         |       |               |     Hz  |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               | 2       |         |
|   |           |         |       |               | .  Bone |         |
|   |           |         |       |               |     con |         |
|   |           |         |       |               | duction |         |
|   |           |         |       |               |     if  |         |
|   |           |         |       |               |     air |         |
|   |           |         |       |               |     con |         |
|   |           |         |       |               | duction |         |
|   |           |         |       |               |     thr |         |
|   |           |         |       |               | esholds |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               |  exceed |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               |    bone |         |
|   |           |         |       |               |     by  |         |
|   |           |         |       |               |     15  |         |
|   |           |         |       |               |     dB  |         |
|   |           |         |       |               |     at  |         |
|   |           |         |       |               |     any |         |
|   |           |         |       |               |     fr  |         |
|   |           |         |       |               | equency |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               | 3.      |         |
|   |           |         |       |               |  Speech |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               | discrim |         |
|   |           |         |       |               | ination |         |
|   |           |         |       |               |     eva |         |
|   |           |         |       |               | luation |         |
|   |           |         |       |               |         |         |
|   |           |         |       |               | OAEs    |         |
|   |           |         |       |               | measure |         |
|   |           |         |       |               | outer   |         |
|   |           |         |       |               | hair    |         |
|   |           |         |       |               | cell    |         |
|   |           |         |       |               | f       |         |
|   |           |         |       |               | unction |         |
|   |           |         |       |               | only.   |         |
|   |           |         |       |               | Because |         |
|   |           |         |       |               | carb    |         |
|   |           |         |       |               | oplatin |         |
|   |           |         |       |               | sele    |         |
|   |           |         |       |               | ctively |         |
|   |           |         |       |               | damages |         |
|   |           |         |       |               | inner   |         |
|   |           |         |       |               | hair    |         |
|   |           |         |       |               | cells,  |         |
|   |           |         |       |               | [p      |         |
|   |           |         |       |               | atients |         |
|   |           |         |       |               | treated |         |
|   |           |         |       |               | with    |         |
|   |           |         |       |               | carb    |         |
|   |           |         |       |               | oplatin |         |
|   |           |         |       |               | should  |         |
|   |           |         |       |               | not be  |         |
|   |           |         |       |               | ev      |         |
|   |           |         |       |               | aluated |         |
|   |           |         |       |               | with    |         |
|   |           |         |       |               | OAEs    |         |
|   |           |         |       |               | ]{.unde |         |
|   |           |         |       |               | rline}. |         |
+---+-----------+---------+-------+---------------+---------+---------+
|   |           | Sensor  | *     | **Treatment   |         |         |
|   |           | ineural | *Host | Factors**\    |         |         |
|   |           | hearing | Facto | \             |         |         |
|   |           | loss\   | rs**\ | Radiation     |         |         |
|   |           | T       | \     | administered  |         |         |
|   |           | innitus | Yo    | prior to      |         |         |
|   |           |         | unger | platinum      |         |         |
|   |           |         | age   | chemotherapy\ |         |         |
|   |           |         | at    | Combined with |         |         |
|   |           |         | treat | other         |         |         |
|   |           |         | ment\ | ototoxic      |         |         |
|   |           |         | CNS   | agents such   |         |         |
|   |           |         | t     | as:           |         |         |
|   |           |         | umor\ |               |         |         |
|   |           |         | CSF   | -   Cisplatin |         |         |
|   |           |         | shun  |               |         |         |
|   |           |         | ting\ | -             |         |         |
|   |           |         | \     |   Carboplatin |         |         |
|   |           |         | *     |     in        |         |         |
|   |           |         | *Trea |               |         |         |
|   |           |         | tment | myeloablative |         |         |
|   |           |         | Facto |     doses     |         |         |
|   |           |         | rs**\ |               |         |         |
|   |           |         | \     | -   Am        |         |         |
|   |           |         | H     | inoglycosides |         |         |
|   |           |         | igher |               |         |         |
|   |           |         | radi  |               |         |         |
|   |           |         | ation |               |         |         |
|   |           |         | dose\ |               |         |         |
|   |           |         | Co    |               |         |         |
|   |           |         | nvent |               |         |         |
|   |           |         | ional |               |         |         |
|   |           |         | (non- |               |         |         |
|   |           |         | confo |               |         |         |
|   |           |         | rmal) |               |         |         |
|   |           |         | radi  |               |         |         |
|   |           |         | ation |               |         |         |
+---+-----------+---------+-------+---------------+---------+---------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Oral Cavity**

**System = Dental\
Score = 1**

  ----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic      **Potential Late  **Risk          **Highest Risk       **Periodic        **Health
  \#**    Agent(s)**         Effects**         Factors**       Factors**            Evaluation**      Counseling Further
                                                                                                      Considerations**
  ------- ------------------ ----------------- --------------- -------------------- ----------------- ------------------
  59      **Cranial\         **Xerostomia**\   **Treatment     **Treatment          **History**\      **Health Links**\
          \                  \                 Factors**\      Factors**\           \                 \
          Nasopharyngeal\    **Salivary gland  \               \                    **Xerostomia**\   **See \"Patient
          \                  dysfunction**     Head and neck   Salivary gland dose  \                 Resources\"
          Oropharyngeal\                       radiation       [\>]{.underline}30   (Yearly)\         field**\
          \                                    involving the   Gy\                  \                 \
          Spine (cervical)\                    parotid gland\  \                    **Physical**\     Dental Health\
          \                                    Higher          **Medical            \                 \
          Cervical (neck)\                     radiation       Conditions**\        **Oral exam**\    **Considerations
          \                                    doses\          \                    \                 for Further
          Supraclavicular\                     Radiomimetic    Chronic GVHD         (Yearly)\         Testing and
          \                                    chemotherapy                         \                 Intervention**\
          Mantle\                              (e.g.,                               **Screening**\    \
          \                                    doxorubicin,                         \                 Supportive care
          Mini-Mantle**                        dactinomycin)                        **Dental exam and with saliva
                                                                                    cleaning**\       substitutes,
                                                                                    \                 moistening agents,
                                                                                    (Every six        and sialogogues
                                                                                    months)           (pilocarpine);
                                                                                                      Regular dental
                                                                                                      care including
                                                                                                      fluoride
                                                                                                      applications

  ----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Dental\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic      **Potential Late    **Risk        **Highest Risk       **Periodic       **Health
  \#**    Agent(s)**         Effects**           Factors**     Factors**            Evaluation**     Counseling Further
                                                                                                     Considerations**
  ------- ------------------ ------------------- ------------- -------------------- ---------------- ------------------
  60      **Cranial\         **Dental            **Host        **Host Factors**\    **Physical**\    **Health Links**\
          \                  abnormalities**\    Factors**\    \                    \                \
          Nasopharyngeal\    \                   \             Age \<5 years at     **Oral exam**\   **See \"Patient
          \                  Tooth/root          Younger age   time of treatment\   \                Resources\"
          Oropharyngeal\     agenesis\           at treatment\ \                    (Yearly)\        field**\
          \                  Microdontia\        Gorlin\'s     **Treatment          \                \
          Spine (cervical)\  Root thinning/      syndrome      Factors**\           **Screening**\   Dental Health\
          \                  shortening\         (nevoid basal \                    \                \
          Cervical (neck)\   Enamel dysplasia\   cell          Dose                 **Dental exam    **Considerations
          \                  Periodontal         carcinoma     [\>]{.underline}10   and cleaning**\  for Further
          Supraclavicular\   disease\            syndrome)\    Gy                   \                Testing and
          \                  Dental caries\      \                                  (Every six       Intervention**\
          Mantle\            Malocclusion\       **Treatment                        months)          \
          \                  Temporomandibular   Factors**\                                          Regular dental
          Mini-Mantle\       joint dysfunction   \                                                   care including
          \                                      Higher                                              fluoride
          TBI**                                  radiation                                           applications.
                                                 dose                                                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](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Dental\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late         **Risk Factors**     **Highest Risk       **Periodic      **Health Counseling
  \#**    Agent(s)**           Effects**                                     Factors**            Evaluation**    Further
                                                                                                                  Considerations**
  ------- -------------------- ------------------------ -------------------- -------------------- --------------- ---------------------
  61      [\>]{.underline}40   **Osteoradionecrosis**   **Treatment          **Treatment          **History**\    **Health Links**\
          Gy to:\                                       Factors**\           Factors**\           \               \
          \                                             \                    \                    **Impaired or   **See \"Patient
          **Cranial\                                    Radiation dose to    Radiation dose to    delayed healing Resources\" field**\
          \                                             bone                 bone                 following       \
          Nasopharyngeal\                               [\>]{.underline}45   [\>]{.underline}50   dental work**\  Osteoradionecrosis\
          \                                             Gy                   Gy                   \               \
          Oropharyngeal\                                                                          **Persistent    **Considerations for
          \                                                                                       jaw pain or     Further Testing and
          Spine (cervical)\                                                                       swelling**\     Intervention**\
          \                                                                                       \               \
          Cervical (neck)\                                                                        **Trismus**\    Imaging studies
          \                                                                                       \               (x-ray, CT scan
          Supraclavicular\                                                                        (As clinically  and/or MRI) may
          \                                                                                       indicated)\     assist in making
          Mantle\                                                                                 \               diagnosis. Surgical
          \                                                                                       **Physical**\   biopsy may be needed
          Mini-Mantle**                                                                           \               to confirm diagnosis.
                                                                                                  **Impaired      Consider hyperbaric
                                                                                                  wound           oxygen treatments.
                                                                                                  healing**\      
                                                                                                  \               
                                                                                                  **Jaw           
                                                                                                  swelling**\     
                                                                                                  \               
                                                                                                  **Trismus**\    
                                                                                                  \               
                                                                                                  (As clinically  
                                                                                                  indicated)      

  -------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Neck/Thyroid**

**System = SMN\
Score = 1**

  --------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic      **Potential   **Risk        **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**         Late          Factors**     Factors**            Evaluation**    Counseling Further
                             Effects**                                                        Considerations**
  ------- ------------------ ------------- ------------- -------------------- --------------- ------------------
  62      **Cranial\         **Thyroid     **Host        **Treatment          **Physical**\   **Health Links**\
          \                  nodules**     Factors**\    Factors**\           \               \
          Nasopharyngeal\                  \             \                    **Thyroid       **See \"Patient
          \                                Younger age   Radiation dose to    exam**\         Resources\"
          Oropharyngeal\                   at treatment\ bone                 \               field**\
          \                                Female sex\   [\>]{.underline}25   (Yearly)        \
          Spine (cervical)\                \             Gy                                   Thyroid Problems\
          \                                **Treatment                                        \
          Cervical (neck)\                 Factors**\                                         **Considerations
          \                                \                                                  for Further
          Supraclavicular\                 Higher                                             Testing and
          \                                radiation                                          Intervention**\
          Mantle\                          dose\                                              \
          \                                Thyroid gland                                      Ultrasound and FNA
          Mini-Mantle\                     directly in                                        for evaluation of
          \                                radiation                                          palpable
          TBI**                            field\                                             nodule(s).
                                           TBI                                                Endocrine and/or
                                                                                              surgical
                                                                                              consultation for
                                                                                              diagnostic biopsy
                                                                                              or thyroidectomy.

  --------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = SMN\
Score = 1**

  -----------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic      **Potential   **Risk Factors**    **Highest   **Periodic      **Health
  \#**    Agent(s)**         Late                              Risk        Evaluation**    Counseling Further
                             Effects**                         Factors**                   Considerations**
  ------- ------------------ ------------- ------------------- ----------- --------------- ------------------
  63      **Cranial\         **Thyroid     **Host Factors**\               **Physical**\   **Health Links**\
          \                  cancer**      \                               \               \
          Nasopharyngeal\                  Younger age at                  **Thyroid       **See \"Patient
          \                                treatment\                      exam**\         Resources\"
          Oropharyngeal\                   Female sex\                     \               field**\
          \                                \                               (Yearly)        \
          Spine (cervical)\                **Treatment                                     Thyroid Problems\
          \                                Factors**\                                      \
          Cervical (neck)\                 \                                               **Considerations
          \                                [\>]{.underline}5                               for Further
          Supraclavicular\                 years after                                     Testing and
          \                                irradiation\                                    Intervention**\
          Mantle\                          Thyroid gland                                   \
          \                                directly in                                     Ultrasound and FNA
          Mini-Mantle\                     radiation field\                                for evaluation of
          \                                TBI\                                            palpable
          TBI**                            Risk increased up                               nodule(s).
                                           to 30 Gy with a                                 Surgical
                                           downturn of risk                                consultation for
                                           after 30 Gy                                     resection. Nuclear
                                                                                           medicine
                                                                                           consultation for
                                                                                           ablation of
                                                                                           residual disease.
                                                                                           Endocrine
                                                                                           consultation for
                                                                                           postoperative
                                                                                           medical
                                                                                           management.

  -----------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  --------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic      **Potential Late     **Risk Factors**     **Highest Risk       **Periodic          **Health
  \#**    Agent(s)**         Effects**                                 Factors**            Evaluation**        Counseling Further
                                                                                                                Considerations**
  ------- ------------------ -------------------- -------------------- -------------------- ------------------- ------------------
  64      **Cranial\         **Hypothyroidism**   **Host Factors**\    **Treatment          **History**\        **Health Links**\
          \                                       \                    Factors**\           \                   \
          Nasopharyngeal\                         Female sex\          \                    **Fatigue**\        **See \"Patient
          \                                       \                    Radiation dose       \                   Resources\"
          Oropharyngeal\                          **Treatment          [\>]{.underline}20   **Weight gain**\    field**\
          \                                       Factors**\           Gy                   \                   \
          Spine (cervical)\                       \                                         **Cold              Thyroid Problems\
          \                                       Radiation dose                            intolerance**\      \
          Cervical (neck)\                        [\>]{.underline}10                        \                   **Counseling**\
          \                                       Gy\                                       **Constipation**\   \
          Supraclavicular\                        Thyroid gland                             \                   Counsel at-risk
          \                                       directly in                               **Dry skin**\       females of
          Mantle\                                 radiation field\                          \                   childbearing
          \                                       TBI                                       **Brittle hair**\   potential to have
          Mini-Mantle\                                                                      \                   their thyroid
          \                                                                                 **Depressed mood**\ levels checked
          TBI**                                                                             \                   prior to
                                                                                            (Yearly; Consider   attempting
                                                                                            more frequent       pregnancy and
                                                                                            screening during    periodically
                                                                                            periods of rapid    throughout
                                                                                            growth)\            pregnancy.\
                                                                                            \                   \
                                                                                            **Physical**\       **Considerations
                                                                                            \                   for Further
                                                                                            **Height**\         Testing and
                                                                                            \                   Intervention**\
                                                                                            **Weight**\         \
                                                                                            \                   Endocrine
                                                                                            **Hair**\           consultation for
                                                                                            \                   medical
                                                                                            **Skin**\           management.
                                                                                            \                   
                                                                                            **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)             

  --------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Endocrine/Metabolic\
Score = 1**

  ------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late     **Risk        **Highest   **Periodic          **Health
  \#**    Agent(s)**           Effects**            Factors**     Risk        Evaluation**        Counseling Further
                                                                  Factors**                       Considerations**
  ------- -------------------- -------------------- ------------- ----------- ------------------- ------------------
  65      [\>]{.underline}40   **Hypothyroidism**   **Treatment               **History**\        **Health Links**\
          Gy to:\                                   Factors**\                \                   \
          \                                         \                         **Heat              **See \"Patient
          **Cranial\                                Higher                    intolerance**\      Resources\"
          \                                         radiation                 \                   field**\
          Nasopharyngeal\                           dose                      **Tachycardia**\    \
          \                                                                   \                   Thyroid Problems\
          Oropharyngeal\                                                      **Palpitations**\   \
          \                                                                   \                   **Considerations
          Spine (cervical)\                                                   **Weight loss**\    for Further
          \                                                                   \                   Testing and
          Cervical (neck)\                                                    **Emotional         Intervention**\
          \                                                                   lability**\         \
          Supraclavicular\                                                    \                   Endocrine
          \                                                                   **Muscular          consultation for
          Mantle\                                                             weakness**\         medical
          \                                                                   \                   management.
          Mini-Mantle**                                                       **Hyperphagia**\    
                                                                              \                   
                                                                              (Yearly)\           
                                                                              \                   
                                                                              **Physical**\       
                                                                              \                   
                                                                              **Eyes**\           
                                                                              \                   
                                                                              **Skin**\           
                                                                              \                   
                                                                              **Thyroid**\        
                                                                              \                   
                                                                              **Cardiac**\        
                                                                              \                   
                                                                              **Neurologic**\     
                                                                              \                   
                                                                              (Yearly)\           
                                                                              \                   
                                                                              **Screening**\      
                                                                              \                   
                                                                              **TSH**\            
                                                                              \                   
                                                                              **Free T4**\        
                                                                              \                   
                                                                              (Yearly)            

  ------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Cardiovascular\
Score = 2A**

  -------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential   **Risk      **Highest   **Periodic      **Health Counseling
  \#**    Agent(s)**           Late          Factors**   Risk        Evaluation**    Further
                               Effects**                 Factors**                   Considerations**
  ------- -------------------- ------------- ----------- ----------- --------------- --------------------
  66      [\>]{.underline}40   **Carotid                             **History**\    **Considerations for
          Gy to:\              artery                                \               Further Testing and
          \                    disease**                             **Memory        Intervention**\
          **Cranial\                                                 impairment**\   \
          \                                                          \               Doppler ultrasound
          Nasopharyngeal\                                            (Yearly)\       of carotid vessels
          \                                                          \               as clinically
          Oropharyngeal\                                             **Physical**\   indicated. MRI with
          \                                                          \               diffusion-weighted
          Spine (cervical)\                                          **Diminished    imaging with MR
          \                                                          carotid         angiography and
          Cervical (neck)\                                           pulses**\       cardiovascular
          \                                                          \               surgery consultation
          Supraclavicular\                                           **Carotid       as clinically
          \                                                          bruits**\       indicated. Consider
          Mantle\                                                    \               color Doppler 10
          \                                                          **Abnormal      years after
          Mini-Mantle**                                              neurologic exam completion of
                                                                     (compromise of  radiation therapy to
                                                                     blood flow to   the neck as a
                                                                     brain)**\       baseline; refer to
                                                                     \               cardiologist if
                                                                     (Yearly)        abnormal.

  -------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Cardiovascular\
Score = 2A**

  ---------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential    **Risk      **Highest   **Periodic       **Health Counseling
  \#**    Agent(s)**           Late Effects** Factors**   Risk        Evaluation**     Further
                                                          Factors**                    Considerations**
  ------- -------------------- -------------- ----------- ----------- ---------------- --------------------
  67      [\>]{.underline}40   **Subclavian                           **Physical**\    **Considerations for
          Gy to:\              artery                                 \                Further Testing and
          \                    disease**                              **Diminished     Intervention**\
          **Spine (cervical)\                                         brachial and     \
          \                                                           radial pulses**\ Doppler ultrasound
          Cervical (neck)\                                            \                of subclavian
          \                                                           **Pallor of      vessels as
          Supraclavicular\                                            upper            clinically
          \                                                           extremities**\   indicated. MRI with
          Mantle\                                                     \                diffusion-weighted
          \                                                           **Coolness of    imaging with MR
          Mini-Mantle**                                               skin**\          angiography and
                                                                      \                cardiovascular
                                                                      **Unequal blood  surgery consultation
                                                                      pressure**\      as clinically
                                                                      \                indicated. Consider
                                                                      (Yearly)         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](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Breast**

**System = SMN\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------
  **Sec \#** **Therapeutic        **Potential   **Risk Factors**     **Highest    **Periodic       **Health
             Agent(s)**           Late                               Risk         Evaluation**     Counseling Further
                                  Effects**                          Factors**                     Considerations**
  ---------- -------------------- ------------- -------------------- ------------ ---------------- ------------------
  68\        [\>]{.underline}20   **Breast      **Host Factors**\    **Host       **Physical**\    **Health Links**\
  \          Gy to:\              cancer**      \                    Factors**\   \                \
  (Female)   \                                  Family history of    \            **Breast exam**\ **See \"Patient
             **Mantle\                          breast cancer\       Female       \                Resources\"
             \                                  \                    gender       (Yearly          field**\
             Mini-Mantle\                       **Treatment                       beginning at     \
             \                                  Factors**\                        puberty until    Breast Cancer\
             Mediastinal\                       \                                 age 25, then     \
             \                                  Higher radiation                  every six        **Counseling**\
             Chest (thorax)\                    dose\                             months)\         \
             \                                  Longer time since                 \                Teach breast
             Axilla**                           radiation                         **Screening**\   self-exam and
                                                ([\>]{.underline}5                \                counsel to perform
                                                years)\                           **Mammogram**\   monthly beginning
                                                \                                 \                at puberty.\
                                                **Info Link**: There              (Yearly,         \
                                                is currently a                    beginning 8      **Considerations
                                                deficiency in the                 years after      for Further
                                                literature regarding              radiation or at  Testing and
                                                whether or not TBI                age 25,          Intervention**\
                                                is a risk factor for              whichever occurs \
                                                the development of                last)\           Surgical
                                                breast cancer.                    \                consultation for
                                                Monitoring of                     **Info Link**:   diagnostic
                                                patients who                      Mammography is   procedure in
                                                received TBI should               currently        patients with
                                                be determined on an               limited in its   breast mass or
                                                individual basis.                 ability to       suspicious
                                                                                  evaluate the     radiographic
                                                                                  premenopausal    finding. Decisions
                                                                                  breast. The role regarding the use
                                                                                  of MRI is        of HRT should be
                                                                                  evolving for     based on current
                                                                                  screening of     literature and
                                                                                  other            should take into
                                                                                  populations at   consideration the
                                                                                  high risk for    risk/benefit ratio
                                                                                  breast cancer    for individual
                                                                                  (e.g.,           patients.
                                                                                  premenopausal    
                                                                                  known or likely  
                                                                                  carriers of gene 
                                                                                  mutation of      
                                                                                  known            
                                                                                  penetrance).     

  -------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Female reproductive\
Score = 1**

  ------------------------------------------------------------------------------------------------------------
  **Sec \#** **Therapeutic        **Potential    **Risk         **Highest   **Periodic      **Health
             Agent(s)**           Late Effects** Factors**      Risk        Evaluation**    Counseling Further
                                                                Factors**                   Considerations**
  ---------- -------------------- -------------- -------------- ----------- --------------- ------------------
  69\        [\>]{.underline}20   **Breast       **Host                     **Physical**\   **Considerations
  \          Gy to:\              tissue         Factors**\                 \               for Further
  (Female)   \                    hypoplasia**   \                          **Breast        Testing and
             **Mantle\                           Prepubertal at             exam**\         Intervention**\
             \                                   time of breast             \               \
             Mini-Mantle\                        irradiation\               (Yearly)        Surgical
             \                                   \                                          consultation for
             Mediastinal\                        **Treatment                                breast
             \                                   Factors**\                                 reconstruction
             Chest (thorax)\                     \                                          after completion
             \                                   Higher                                     of growth.
             Whole lung\                         radiation dose                             
             \                                                                              
             Axilla\                                                                        
             \                                                                              
             TBI**                                                                          

  ------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Lungs**

**System = Pulmonary\
Score = 1**

+---+--------+--------+---------------+-------+--------+-------------+
| * | *      | **Pot  | **Risk        | **Hi  | **Pe   | **Health    |
| * | *Thera | ential | Factors**     | ghest | riodic | Counseling  |
| S | peutic | Late   |               | Risk  | Evalua | Further     |
| e | Agen   | Eff    |               | Fact  | tion** | Consi       |
| c | t(s)** | ects** |               | ors** |        | derations** |
| \ |        |        |               |       |        |             |
| # |        |        |               |       |        |             |
| * |        |        |               |       |        |             |
| * |        |        |               |       |        |             |
+===+========+========+===============+=======+========+=============+
| 7 | **M    | **Pul  | **Host        | *     | **Hist | **Health    |
| 0 | antle\ | monary | Factors**\    | *Trea | ory**\ | Links**\    |
|   | \      | toxic  | \             | tment | \      | \           |
|   | Medias | ity**\ | Younger age   | Facto | **Co   | **See       |
|   | tinal\ | \      | at            | rs**\ | ugh**\ | \"Patient   |
|   | \      | Pul    | irradiation\  | \     | \      | Resources\" |
|   | Chest  | monary | \             | Radi  | **     | field**\    |
|   | (th    | fib    | **Treatment   | ation | SOB**\ | \           |
|   | orax)\ | rosis\ | Factors**\    | dose  | \      | Pulmonary   |
|   | \      | Inters | \             | [\>   | **     | Health\     |
|   | Whole  | titial | Radiation     | ]{.un | DOE**\ | \           |
|   | lung\  | pneumo | dose          | derli | \      | **R         |
|   | \      | nitis\ | [\>]{         | ne}15 | *      | esources**\ |
|   | TBI**  | Restr  | .underline}10 | Gy\   | *Wheez | \           |
|   |        | ictive | Gy\           | TBI   | ing**\ | Extensive   |
|   |        | lung   | Chest         | [\    | \      | information |
|   |        | di     | radiation     | >]{.u | (Ye    | regarding   |
|   |        | sease\ | combined with | nderl | arly)\ | smoking     |
|   |        | Obstr  | TBI\          | ine}6 | \      | cessation   |
|   |        | uctive | Radiation     | Gy in | *      | is          |
|   |        | lung   | combined      | s     | *Physi | available   |
|   |        | d      | with:         | ingle | cal**\ | for         |
|   |        | isease |               | frac  | \      | patients on |
|   |        |        | -   Bleomycin | tion\ | **Pul  | the NCI\'s  |
|   |        |        |               | TBI   | monary | website:    |
|   |        |        | -   Busulfan  | [\>   | e      | [ww         |
|   |        |        |               | ]{.un | xam**\ | w.smokefree |
|   |        |        | -             | derli | \      | .gov](http: |
|   |        |        |    Carmustine | ne}12 | (Ye    | //www.smoke |
|   |        |        |     (BCNU)    | Gy    | arly)\ | free.gov/)\ |
|   |        |        |               | fr    | \      | \           |
|   |        |        | -   Lomustine | actio | **     | **Co        |
|   |        |        |     (CCNU)    | nated | Screen | unseling**\ |
|   |        |        |               |       | ing**\ | \           |
|   |        |        | -             |       | \      | Counsel     |
|   |        |        |  Radiomimetic |       | *      | regarding   |
|   |        |        |               |       | *Chest | tobacco     |
|   |        |        |  chemotherapy |       | x-     | avoida      |
|   |        |        |     (e.g.,    |       | ray**\ | nce/smoking |
|   |        |        |               |       | \      | cessation.  |
|   |        |        |  doxorubicin, |       | **PFTs | Due to the  |
|   |        |        |               |       | (inc   | potential   |
|   |        |        | dactinomycin) |       | luding | pulmonary   |
|   |        |        |               |       | DLCO   | toxicity of |
|   |        |        | **Medical     |       | and    | this        |
|   |        |        | Conditions**\ |       | sp     | therapy,    |
|   |        |        | \             |       | iromet | patients    |
|   |        |        | Atopic        |       | ry)**\ | who desire  |
|   |        |        | history\      |       | \      | to SCUBA    |
|   |        |        | \             |       | (Ba    | dive should |
|   |        |        | **Health      |       | seline | be advised  |
|   |        |        | Behaviors**\  |       | at     | to obtain   |
|   |        |        | \             |       | entry  | medical     |
|   |        |        | Smoking       |       | into   | clearance   |
|   |        |        |               |       | lon    | from a      |
|   |        |        |               |       | g-term | diving      |
|   |        |        |               |       | foll   | medicine    |
|   |        |        |               |       | ow-up. | s           |
|   |        |        |               |       | Repeat | pecialist.\ |
|   |        |        |               |       | as     | \           |
|   |        |        |               |       | clin   | **Con       |
|   |        |        |               |       | ically | siderations |
|   |        |        |               |       | ind    | for Further |
|   |        |        |               |       | icated | Testing and |
|   |        |        |               |       | in     | Inte        |
|   |        |        |               |       | pa     | rvention**\ |
|   |        |        |               |       | tients | \           |
|   |        |        |               |       | with   | In patients |
|   |        |        |               |       | ab     | with        |
|   |        |        |               |       | normal | abnormal    |
|   |        |        |               |       | r      | PFTs and/or |
|   |        |        |               |       | esults | CXR,        |
|   |        |        |               |       | or     | consider    |
|   |        |        |               |       | progr  | repeat      |
|   |        |        |               |       | essive | evaluation  |
|   |        |        |               |       | pul    | prior to    |
|   |        |        |               |       | monary | general     |
|   |        |        |               |       | d      | anesthesia. |
|   |        |        |               |       | ysfunc | Pulmonary   |
|   |        |        |               |       | tion.) | c           |
|   |        |        |               |       |        | onsultation |
|   |        |        |               |       |        | for         |
|   |        |        |               |       |        | patients    |
|   |        |        |               |       |        | with        |
|   |        |        |               |       |        | symptomatic |
|   |        |        |               |       |        | pulmonary   |
|   |        |        |               |       |        | d           |
|   |        |        |               |       |        | ysfunction. |
|   |        |        |               |       |        | Influenza   |
|   |        |        |               |       |        | and         |
|   |        |        |               |       |        | P           |
|   |        |        |               |       |        | neumococcal |
|   |        |        |               |       |        | va          |
|   |        |        |               |       |        | ccinations. |
+---+--------+--------+---------------+-------+--------+-------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Heart**

**System = Cardiovascular\
Score = 1**

+---+-----+------+-----------+-----+-----+------------------------------+
| * | *   | **P  | **Risk    | **H | *   | **Health Counseling Further  |
| * | *Th | oten | Factors** | igh | *Pe | Considerations**             |
| S | era | tial |           | est | rio |                              |
| e | peu | Late |           | R   | dic |                              |
| c | tic | E    |           | isk | Eva |                              |
| \ | A   | ffec |           | Fac | lua |                              |
| # | gen | ts** |           | tor | tio |                              |
| * | t(s |      |           | s** | n** |                              |
| * | )** |      |           |     |     |                              |
+===+=====+======+===========+=====+=====+==============================+
| 7 | **M | *    | **Host    | **H | **H | **Health Links**\            |
| 1 | ant | *Car | F         | ost | ist | \                            |
|   | le\ | diac | actors**\ | F   | ory | **See \"Patient Resources\"  |
|   | \   | tox  | \         | act | **\ | field**\                     |
|   | Med | icit | Younger   | ors | \   | \                            |
|   | ias | y**\ | age at    | **\ | **  | Heart Health\                |
|   | tin | \    | irr       | \   | SOB | Diet and Physical Activity\  |
|   | al\ | Co   | adiation\ | Fem | **\ | \                            |
|   | \   | nges | Family    | ale | \   | **Resources**\               |
|   | Ch  | tive | history   | s   | **  | \                            |
|   | est | h    | of        | ex\ | DOE | A downloadable wallet card   |
|   | (th | eart | dysl      | Bl  | **\ | is available from the AHA    |
|   | ora | fail | ipidemia\ | ack | \   | website for patients         |
|   | x)\ | ure\ | Coronary  | /of | **  | requiring endocarditis       |
|   | \   | Car  | artery    | A   | Ort | prophylaxis:                 |
|   | A   | diom | disease\  | fri | hop | [www.ame                     |
|   | xil | yopa | \         | can | nea | ricanheart.org/downloadable/ |
|   | la\ | thy\ | **        | de  | **\ | heart/1023826501754walletcar |
|   | \   | P    | Treatment | sce | \   | d.pdf](http://www.americanhe |
|   | Sp  | eric | F         | nt\ | *   | art.org/downloadable/heart/1 |
|   | ine | ardi | actors**\ | Y   | *Ch | 023826501754walletcard.pdf)\ |
|   | (t  | tis\ | \         | oun | est | \                            |
|   | hor | Per  | Radiation | ger | p   | **Counseling**\              |
|   | aci | icar | dose      | t   | ain | \                            |
|   | c)\ | dial | [\>]{.und | han | **\ | Counsel patients with        |
|   | \   | f    | erline}20 | age | \   | prolonged QTc interval about |
|   | Wh  | ibro | Gy to     | 5   | **  | use of medications that may  |
|   | ole | sis\ | chest\    | ye  | Pal | further prolong the QTc      |
|   | ab  | Valv | TBI\      | ars | pit | interval (e.g., tricyclic    |
|   | dom | ular | Combined  | at  | ati | anti-depressants,            |
|   | en\ | dise | with      | t   | ons | antifungals, macrolide       |
|   | \   | ase\ | rad       | ime | **\ | antibiotics, metronidazole). |
|   | All | My   | iomimetic | of  | \   | Counsel regarding            |
|   | up  | ocar | che       | t   | *   | maintaining appropriate      |
|   | per | dial | motherapy | rea | *If | weight, blood pressure, and  |
|   | abd | inf  | (e.g.,    | tme | un  | heart-healthy diet. Counsel  |
|   | omi | arct | dox       | nt\ | der | regarding endocarditis       |
|   | nal | ion\ | orubicin, | \   | 25  | prophylaxis if valvular      |
|   | fi  | Arr  | dacti     | **  | yea | abnormalities present.       |
|   | eld | hyth | nomycin)\ | Tre | rs: | Counsel regarding            |
|   | s** | mia\ | Combined  | atm | Abd | appropriate exercise.        |
|   |     | Ath  | with      | ent | omi | Aerobic exercise is          |
|   |     | eros | other     | F   | nal | generally safe and should be |
|   |     | cler | ca        | act | sy  | encouraged for most          |
|   |     | otic | rdiotoxic | ors | mpt | patients. Intensive          |
|   |     | h    | chem      | **\ | oms | isometric activities (e.g.,  |
|   |     | eart | otherapy: | \   | (n  | heavy weight lifting,        |
|   |     | dis  |           | A   | aus | wrestling) should generally  |
|   |     | ease | -   Anthr | nte | ea, | be avoided. Limited high     |
|   |     |      | acyclines | rio | vom | repetition weight lifting    |
|   |     |      |           | rly | iti | (i.e., lifting a lighter     |
|   |     |      | -         | -we | ng) | weight with ease no more     |
|   |     |      |   Cycloph | igh | **\ | than 15 to 20 times in a     |
|   |     |      | osphamide | ted | \   | row) is much less stressful  |
|   |     |      |     con   | rad | (Ye | to the heart and is more     |
|   |     |      | ditioning | iat | arl | likely to be safe. Patients  |
|   |     |      |     for   | ion | y)\ | who choose to engage in      |
|   |     |      |     HCT   | f   | \   | strenuous or varsity team    |
|   |     |      |           | iel | **I | sports should discuss        |
|   |     |      | -         | ds\ | nfo | appropriate guidelines and a |
|   |     |      | Amsacrine | L   | L   | plan for ongoing monitoring  |
|   |     |      |           | ack | ink | with a cardiologist.\        |
|   |     |      | **Medical | of  | **: | \                            |
|   |     |      | Cond      | s   | E   | **Considerations for Further |
|   |     |      | itions**\ | ubc | xer | Testing and Intervention**\  |
|   |     |      | \         | ari | tio | \                            |
|   |     |      | Hype      | nal | nal | Cardiology consultation for  |
|   |     |      | rtension\ | s   | in  | patients with subclinical    |
|   |     |      | Obesity\  | hie | tol | abnormalities on screening   |
|   |     |      | Dysl      | ldi | era | evaluations or with left     |
|   |     |      | ipidemia\ | ng\ | nce | ventricular dysfunction,     |
|   |     |      | Diabetes  | Do  | is  | dysrhythmia or prolonged QTc |
|   |     |      | mellitus\ | ses | un  | interval. Additional         |
|   |     |      | C         | [\> | com | cardiology evaluation for    |
|   |     |      | ongenital | ]{. | mon | patients who are pregnant or |
|   |     |      | heart     | und | in  | planning pregnancy who: (1)  |
|   |     |      | disease\  | erl | yo  | received [\>]{.underline}30  |
|   |     |      | Febrile   | ine | ung | Gy chest radiation, or (2)   |
|   |     |      | illness\  | }30 | pa  | received chest radiation in  |
|   |     |      | P         | Gy  | tie | combination with cardiotoxic |
|   |     |      | regnancy\ | in  | nts | chemotherapy (anthracyclines |
|   |     |      | Premature | pa  | (\  | or high-dose                 |
|   |     |      | ovarian   | tie | <25 | cyclophosphamide).           |
|   |     |      | failure   | nts | y   | Evaluation to include        |
|   |     |      | (un       | who | ear | echocardiogram before and    |
|   |     |      | treated)\ | h   | s). | periodically during          |
|   |     |      | \         | ave | Abd | pregnancy (especially during |
|   |     |      | **Health  | re  | omi | third trimester) and         |
|   |     |      | Beh       | cei | nal | monitoring during labor and  |
|   |     |      | aviors**\ | ved | sy  | delivery due to risk of      |
|   |     |      | \         | ant | mpt | cardiac failure. Consider    |
|   |     |      | Smoking\  | hra | oms | cardiology consultation (5   |
|   |     |      | Isometric | cyc | (n  | to 10 years after radiation) |
|   |     |      | exercise\ | lin | aus | to evaluate risk for         |
|   |     |      | Drug use  | es\ | ea, | coronary artery disease in   |
|   |     |      | (e.g.,    | Do  | e   | patients who received        |
|   |     |      | cocaine,  | ses | mes | [\>]{.underline}40 Gy chest  |
|   |     |      | diet      | [\> | is) | radiation alone or           |
|   |     |      | pills,    | ]{. | may | [\>]{.underline}30 Gy chest  |
|   |     |      | ephedra)  | und | be  | radiation plus               |
|   |     |      |           | erl | ob  | anthracycline. Consider      |
|   |     |      |           | ine | ser | excess risk of isometric     |
|   |     |      |           | }40 | ved | exercise program in any      |
|   |     |      |           | Gy  | m   | high-risk patient defined as |
|   |     |      |           | in  | ore | needing screening every 1 or |
|   |     |      |           | pa  | f   | 2 years.                     |
|   |     |      |           | tie | req |                              |
|   |     |      |           | nts | uen |                              |
|   |     |      |           | who | tly |                              |
|   |     |      |           | h   | t   |                              |
|   |     |      |           | ave | han |                              |
|   |     |      |           | not | e   |                              |
|   |     |      |           | re  | xer |                              |
|   |     |      |           | cei | tio |                              |
|   |     |      |           | ved | nal |                              |
|   |     |      |           | ant | d   |                              |
|   |     |      |           | hra | ysp |                              |
|   |     |      |           | cyc | nea |                              |
|   |     |      |           | lin | or  |                              |
|   |     |      |           | es\ | ch  |                              |
|   |     |      |           | Lon | est |                              |
|   |     |      |           | ger | p   |                              |
|   |     |      |           | t   | ain |                              |
|   |     |      |           | ime | in  |                              |
|   |     |      |           | si  | yo  |                              |
|   |     |      |           | nce | ung |                              |
|   |     |      |           | tre | p   |                              |
|   |     |      |           | atm | ati |                              |
|   |     |      |           | ent | ent |                              |
|   |     |      |           |     | s.\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | *   |                              |
|   |     |      |           |     | *Ph |                              |
|   |     |      |           |     | ysi |                              |
|   |     |      |           |     | cal |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **C |                              |
|   |     |      |           |     | ard |                              |
|   |     |      |           |     | iac |                              |
|   |     |      |           |     | mur |                              |
|   |     |      |           |     | mur |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **  |                              |
|   |     |      |           |     | S3, |                              |
|   |     |      |           |     | S4  |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **  |                              |
|   |     |      |           |     | Inc |                              |
|   |     |      |           |     | rea |                              |
|   |     |      |           |     | sed |                              |
|   |     |      |           |     | P2  |                              |
|   |     |      |           |     | so  |                              |
|   |     |      |           |     | und |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | *   |                              |
|   |     |      |           |     | *Pe |                              |
|   |     |      |           |     | ric |                              |
|   |     |      |           |     | ard |                              |
|   |     |      |           |     | ial |                              |
|   |     |      |           |     | rub |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | *   |                              |
|   |     |      |           |     | *Ra |                              |
|   |     |      |           |     | les |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **W |                              |
|   |     |      |           |     | hee |                              |
|   |     |      |           |     | zes |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **J |                              |
|   |     |      |           |     | ugu |                              |
|   |     |      |           |     | lar |                              |
|   |     |      |           |     | ven |                              |
|   |     |      |           |     | ous |                              |
|   |     |      |           |     | d   |                              |
|   |     |      |           |     | ist |                              |
|   |     |      |           |     | ens |                              |
|   |     |      |           |     | ion |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **P |                              |
|   |     |      |           |     | eri |                              |
|   |     |      |           |     | phe |                              |
|   |     |      |           |     | ral |                              |
|   |     |      |           |     | ed  |                              |
|   |     |      |           |     | ema |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | (Ye |                              |
|   |     |      |           |     | arl |                              |
|   |     |      |           |     | y)\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **  |                              |
|   |     |      |           |     | Scr |                              |
|   |     |      |           |     | een |                              |
|   |     |      |           |     | ing |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **F |                              |
|   |     |      |           |     | ast |                              |
|   |     |      |           |     | ing |                              |
|   |     |      |           |     | g   |                              |
|   |     |      |           |     | luc |                              |
|   |     |      |           |     | ose |                              |
|   |     |      |           |     | and |                              |
|   |     |      |           |     | li  |                              |
|   |     |      |           |     | pid |                              |
|   |     |      |           |     | p   |                              |
|   |     |      |           |     | rof |                              |
|   |     |      |           |     | ile |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | (Ev |                              |
|   |     |      |           |     | ery |                              |
|   |     |      |           |     | 3   |                              |
|   |     |      |           |     | to  |                              |
|   |     |      |           |     | 5   |                              |
|   |     |      |           |     | yea |                              |
|   |     |      |           |     | rs. |                              |
|   |     |      |           |     | If  |                              |
|   |     |      |           |     | abn |                              |
|   |     |      |           |     | orm |                              |
|   |     |      |           |     | al, |                              |
|   |     |      |           |     | re  |                              |
|   |     |      |           |     | fer |                              |
|   |     |      |           |     | for |                              |
|   |     |      |           |     | o   |                              |
|   |     |      |           |     | ngo |                              |
|   |     |      |           |     | ing |                              |
|   |     |      |           |     | m   |                              |
|   |     |      |           |     | ana |                              |
|   |     |      |           |     | gem |                              |
|   |     |      |           |     | ent |                              |
|   |     |      |           |     | .)\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **  |                              |
|   |     |      |           |     | EKG |                              |
|   |     |      |           |     | (i  |                              |
|   |     |      |           |     | ncl |                              |
|   |     |      |           |     | ude |                              |
|   |     |      |           |     | e   |                              |
|   |     |      |           |     | val |                              |
|   |     |      |           |     | uat |                              |
|   |     |      |           |     | ion |                              |
|   |     |      |           |     | of  |                              |
|   |     |      |           |     | QTc |                              |
|   |     |      |           |     | int |                              |
|   |     |      |           |     | erv |                              |
|   |     |      |           |     | al) |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | (Ba |                              |
|   |     |      |           |     | sel |                              |
|   |     |      |           |     | ine |                              |
|   |     |      |           |     | at  |                              |
|   |     |      |           |     | en  |                              |
|   |     |      |           |     | try |                              |
|   |     |      |           |     | i   |                              |
|   |     |      |           |     | nto |                              |
|   |     |      |           |     | lon |                              |
|   |     |      |           |     | g-t |                              |
|   |     |      |           |     | erm |                              |
|   |     |      |           |     | fol |                              |
|   |     |      |           |     | low |                              |
|   |     |      |           |     | up. |                              |
|   |     |      |           |     | Rep |                              |
|   |     |      |           |     | eat |                              |
|   |     |      |           |     | as  |                              |
|   |     |      |           |     | c   |                              |
|   |     |      |           |     | lin |                              |
|   |     |      |           |     | ica |                              |
|   |     |      |           |     | lly |                              |
|   |     |      |           |     | ind |                              |
|   |     |      |           |     | ica |                              |
|   |     |      |           |     | ted |                              |
|   |     |      |           |     | .)\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | **E |                              |
|   |     |      |           |     | CHO |                              |
|   |     |      |           |     | **\ |                              |
|   |     |      |           |     | \   |                              |
|   |     |      |           |     | (Ba |                              |
|   |     |      |           |     | sel |                              |
|   |     |      |           |     | ine |                              |
|   |     |      |           |     | at  |                              |
|   |     |      |           |     | en  |                              |
|   |     |      |           |     | try |                              |
|   |     |      |           |     | i   |                              |
|   |     |      |           |     | nto |                              |
|   |     |      |           |     | lon |                              |
|   |     |      |           |     | g-t |                              |
|   |     |      |           |     | erm |                              |
|   |     |      |           |     | fol |                              |
|   |     |      |           |     | low |                              |
|   |     |      |           |     | up, |                              |
|   |     |      |           |     | t   |                              |
|   |     |      |           |     | hen |                              |
|   |     |      |           |     | per |                              |
|   |     |      |           |     | iod |                              |
|   |     |      |           |     | ica |                              |
|   |     |      |           |     | lly |                              |
|   |     |      |           |     | ba  |                              |
|   |     |      |           |     | sed |                              |
|   |     |      |           |     | on  |                              |
|   |     |      |           |     | age |                              |
|   |     |      |           |     | at  |                              |
|   |     |      |           |     | t   |                              |
|   |     |      |           |     | rea |                              |
|   |     |      |           |     | tme |                              |
|   |     |      |           |     | nt, |                              |
|   |     |      |           |     | rad |                              |
|   |     |      |           |     | iat |                              |
|   |     |      |           |     | ion |                              |
|   |     |      |           |     | do  |                              |
|   |     |      |           |     | se, |                              |
|   |     |      |           |     | and |                              |
|   |     |      |           |     | c   |                              |
|   |     |      |           |     | umu |                              |
|   |     |      |           |     | lat |                              |
|   |     |      |           |     | ive |                              |
|   |     |      |           |     | a   |                              |
|   |     |      |           |     | nth |                              |
|   |     |      |           |     | rac |                              |
|   |     |      |           |     | ycl |                              |
|   |     |      |           |     | ine |                              |
|   |     |      |           |     | dos |                              |
|   |     |      |           |     | e - |                              |
|   |     |      |           |     | *   |                              |
|   |     |      |           |     | see |                              |
|   |     |      |           |     | n   |                              |
|   |     |      |           |     | ext |                              |
|   |     |      |           |     | ta  |                              |
|   |     |      |           |     | ble |                              |
|   |     |      |           |     | *.) |                              |
+---+-----+------+-----------+-----+-----+------------------------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Recommended Frequency of Echocardiogram**

  -------------------------------------------------------------------------------------
  **Age at            **Radiation Dose**   **Anthracycline       **Recommended
  Treatment\***                            Dose\*\***            Frequency**
  ------------------- -------------------- --------------------- ----------------------
  \<5 years old       Any                  None                  Every 2 years

                                           Any                   Every year

  [\>]{.underline}5   \<30 Gy              None                  Every 5 years
  years old                                                      

                      [\>]{.underline}30   None                  Every 2 years
                      Gy                                         

                      Any                  \<300 mg/m^2^         Every 2 years

                                           [\>]{.underline}300   Every year
                                           mg/m^2^               

  Any age with serial                                            Every year
  decrease in                                                    
  function                                                       
  -------------------------------------------------------------------------------------

\*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        **Potential Late   **Risk        **Highest   **Periodic            **Health Counseling
  \#**    Agent(s)**           Effects**          Factors**     Risk        Evaluation**          Further
                                                                Factors**                         Considerations**
  ------- -------------------- ------------------ ------------- ----------- --------------------- ---------------------
  72      [\>]{.underline}40   **Functional       **Treatment               **Physical**\         **Health Links**\
          Gy to:\              asplenia**\        Factors**\                \                     \
          \                    \                  \                         **Physical exam at    **See \"Patient
          **Spleen (entire)\   At risk for        Higher                    time of febrile       Resources\" field**\
          \                    life-threatening   radiation                 illness to evaluate   \
          Whole abdomen\       infection with     dose to                   degree of illness and Splenic Precautions\
          \                    encapsulated       entire spleen             potential source of   \
          Left upper quadrant\ organisms (e.g.,                             infection** (When     **Counseling**\
          \                    Haemophilus                                  febrile T             \
          Inverted Y**         influenzae,                                  [\>]{.underline}101   Medical alert
                               streptococcus                                degrees F)\           bracelet/card noting
                               pneumoniae,                                  \                     functional asplenia;
                               meningococcus)                               (Yearly)\             Counsel to avoid
                                                                            \                     malaria and tick
                                                                            **Screening**\        bites if living in or
                                                                            \                     visiting endemic
                                                                            **Blood culture**\    areas.\
                                                                            \                     \
                                                                            (When febrile T       **Considerations for
                                                                            [\>]{.underline}101   Further Testing and
                                                                            degrees F)            Intervention**\
                                                                                                  \
                                                                                                  In patients with T
                                                                                                  [\>]{.underline}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
                                                                                                  [\>]{.underline}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
                                                                                                  [\>]{.underline}10
                                                                                                  years old at
                                                                                                  [\>]{.underline}5
                                                                                                  years after previous
                                                                                                  dose.

  ---------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to GI/Hepatic System**

**System = GI/Hepatic\
Score = 1**

  -----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential    **Risk Factors**   **Highest Risk       **Periodic       **Health
  \#**    Agent(s)**           Late Effects**                    Factors**            Evaluation**     Counseling Further
                                                                                                       Considerations**
  ------- -------------------- -------------- ------------------ -------------------- ---------------- ------------------
  73      [\>]{.underline}30   **Esophageal   **Treatment        **Treatment          **History**\     **Health Links**\
          Gy to:\              stricture**    Factors**\         Factors**\           \                \
          \                                   \                  \                    **Dysphagia**\   **See \"Patient
          **Cervical (neck)\                  Higher radiation   Radiation dose       \                Resources\"
          \                                   dose\              [\>]{.underline}40   **Heartburn**\   field**\
          Spine (cervical,                    Radiomimetic       Gy                   \                \
          thoracic)\                          chemotherapy                            (Yearly)         Gastrointestinal
          \                                   (e.g.,                                                   Health\
          Supraclavicular\                    doxorubicin,                                             \
          \                                   actinomycin)\                                            **Considerations
          Mantle\                             \                                                        for Further
          \                                   **Medical                                                Testing and
          Mini-Mantle\                        Conditions**\                                            Intervention**\
          \                                   \                                                        \
          Mediastinal\                        Gastroesophageal                                         Surgical and/or
          \                                   reflux                                                   gastroenterology
          Chest (thorax)\                                                                              consultation for
          \                                                                                            symptomatic
          Whole abdomen\                                                                               patients.
          \                                                                                            
          All upper abdominal                                                                          
          fields**                                                                                     

  -----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = GI/Hepatic\
Score = 1**

  -----------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential     **Risk          **Highest Risk       **Periodic          **Health Counseling Further
  \#**    Agent(s)**           Late Effects**  Factors**       Factors**            Evaluation**        Considerations**
  ------- -------------------- --------------- --------------- -------------------- ------------------- -----------------------------
  74      [\>]{.underline}30   **Hepatic       **Treatment     **Treatment          **Physical**\       **Health Links**\
          Gy to:\              fibrosis**\     Factors**\      Factors**\           \                   \
          \                    \               \               \                    **Jaundice**\       **See \"Patient Resources\"
          **Whole abdomen**\   **Cirrhosis**   Higher          Dose                 \                   field**\
          \                                    radiation dose\ [\>]{.underline}40   **Spider            \
          **All upper                          \               Gy to at least 1/3   angiomas**\         Liver Health\
          abdominal fields**                   **Medical       of liver volume\     \                   \
                                               Conditions**\   Dose 20 to 30 Gy to  **Palmar            **Considerations for Further
                                               \               entire liver         erythema**\         Testing and Intervention**\
                                               Chronic                              \                   \
                                               hepatitis\                           **Xanthomata**\     Prothrombin time for
                                               History of VOD\                      \                   evaluation of hepatic
                                               \                                    **Hepatomegaly**\   synthetic function in
                                               **Health                             \                   patients with abnormal liver
                                               Behaviors**\                         **Splenomegaly**\   screening tests. Screen for
                                               \                                    \                   viral hepatitis in patients
                                               Alcohol use                          (Yearly)\           with persistently abnormal
                                                                                    \                   liver function or any patient
                                                                                    **Screening**\      transfused prior to 1993.
                                                                                    \                   Gastroenterology/hepatology
                                                                                    **ALT**\            consultation in patients with
                                                                                    \                   persistent liver dysfunction.
                                                                                    **AST**\            Hepatitis A and B
                                                                                    \                   immunizations in patients
                                                                                    **Bilirubin**\      lacking immunity.
                                                                                    \                   
                                                                                    (Baseline at entry  
                                                                                    into long-term      
                                                                                    follow-up. Repeat   
                                                                                    as clinically       
                                                                                    indicated.)         

  -----------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = GI/Hepatic\
Score = 2B**

  ------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late     **Risk Factors**  **Highest   **Periodic      **Health
  \#**    Agent(s)**           Effects**                              Risk        Evaluation**    Counseling Further
                                                                      Factors**                   Considerations**
  ------- -------------------- -------------------- ----------------- ----------- --------------- ------------------
  75      [\>]{.underline}30   **Cholelithiasis**   **Host Factors**\             **History**\    **Health Links**\
          Gy to:\                                   \                             \               \
          \                                         Ileal conduit\                **Colicky       **See \"Patient
          **Whole abdomen**\                        Obesity\                      abdominal pain  Resources\"
          \                                         Pregnancy\                    related to      field**\
          **All upper                               Family history of             fatty food      \
          abdominal fields**                        cholelithiasis\               intake**\       Gastrointestinal
                                                    \                             \               Health\
                                                    **Treatment                   **Excessive     \
                                                    Factors**\                    flatulence**\   **Considerations
                                                    \                             \               for Further
                                                    Abdominal                     (Yearly and     Testing and
                                                    surgery\                      PRN)\           Intervention**\
                                                    Abdominal                     \               \
                                                    radiation\                    **Physical**\   Consider
                                                    TPN                           \               gallbladder
                                                                                  **RUQ or        ultrasound in
                                                                                  epigastric      patients with
                                                                                  tenderness**\   chronic abdominal
                                                                                  \               pain
                                                                                  **Positive      
                                                                                  Murphy\'s       
                                                                                  sign**\         
                                                                                  \               
                                                                                  (Yearly and     
                                                                                  PRN)            

  ------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = GI/Hepatic\
Score = 1**

  ----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential     **Risk        **Highest Risk       **Periodic          **Health
  \#**    Agent(s)**           Late Effects**  Factors**     Factors**            Evaluation**        Counseling Further
                                                                                                      Considerations**
  ------- -------------------- --------------- ------------- -------------------- ------------------- ------------------
  76      [\>]{.underline}30   **Bowel         **Treatment   **Treatment          **History**\        **Health Links**\
          Gy to:\              obstruction**   Factors**\    Factors**\           \                   \
          \                                    \             \                    **Abdominal pain**\ **See \"Patient
          **Whole abdomen**\                   Higher        Radiation dose       \                   Resources\"
          \                                    radiation     [\>]{.underline}45   **Emesis**\         field**\
          **All upper                          dose to       Gy\                  \                   \
          abdominal fields**\                  bowel\        (Obstruction may     **Distention**\     Gastrointestinal
          \                                    Abdominal     occur in people who  \                   Health\
          **Pelvic**\                          surgery\      received lower doses **Vomiting**\       \
          \                                    \             of abdominal         \                   **Considerations
          **Spine (thoracic,                   **Info        radiation during     **Constipation**\   for Further
          lumbar, sacral)**                    Link**: Bowel childhood)           \                   Testing and
                                               obstruction                        (With clinical      Intervention**\
                                               is rarely                          symptoms of         \
                                               seen in                            obstruction)\       Obtain KUB in
                                               individuals                        \                   patients with
                                               treated with                       **Physical**\       clinical symptoms
                                               abdominal                          \                   of obstruction.
                                               radiation who                      **Tenderness**\     Surgical
                                               have not had                       \                   consultation in
                                               abdominal                          **Abdominal         patients
                                               surgery                            guarding**\         unresponsive to
                                                                                  \                   medical
                                                                                  **Distension**\     management.
                                                                                  \                   
                                                                                  (With clinical      
                                                                                  symptoms of         
                                                                                  obstruction)        

  ----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = GI/Hepatic\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late   **Risk        **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**           Effects**          Factors**     Factors**            Evaluation**    Counseling Further
                                                                                                     Considerations**
  ------- -------------------- ------------------ ------------- -------------------- --------------- ------------------
  77      [\>]{.underline}30   **Chronic          **Treatment   **Treatment          **History**\    **Health Links**\
          Gy to:\              enterocolitis**\   Factors**\    Factors**\           \               \
          \                    \                  \             \                    **Nausea**\     **See \"Patient
          **Whole abdomen**\   **Fistula**\       Higher        Radiation dose       \               Resources\"
          \                    \                  radiation     [\>]{.underline}45   **Vomiting**\   field**\
          **All upper          **Strictures**     dose to       Gy                   \               \
          abdominal fields**\                     bowel\                             **Abdominal     Gastrointestinal
          \                                       Abdominal                          pain**\         Health\
          **Pelvic**\                             surgery                            \               \
          \                                                                          **Diarrhea**\   **Considerations
          **Spine (thoracic,                                                         \               for Further
          lumbar, sacral)**                                                          (Yearly)        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](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = SMN\
Score = 2A**

  -------------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late     **Risk Factors**     **Highest Risk     **Periodic         **Health
  \#**    Agent(s)**           Effects**                                 Factors**          Evaluation**       Counseling Further
                                                                                                               Considerations**
  ------- -------------------- -------------------- -------------------- ------------------ ------------------ ------------------
  78      [\>]{.underline}30   **Colorectal         **Host Factors**\    **Host Factors**\  **Screening**\     **Health Links**\
          Gy to:\              cancer**\            \                    \                  \                  \
          \                    \                    Current age          Personal history   **Colonoscopy**\   **See \"Patient
          **Whole abdomen**\   **Info Link**:       [\>]{.underline}50   of ulcerative      \                  Resources\"
          \                    Reports of           years\               colitis,           (Every 5 years     field**\
          **All upper          colorectal cancer in \                    gastrointestinal   \[minimum\]        \
          abdominal fields**\  cohorts of long-term **Treatment          malignancy,        beginning at 10    Colorectal Cancer\
          \                    survivors suggest    Factors**\           adenomatous        years after        \
          **Pelvic**\          that radiation       \                    polyps, or         radiation or at    **Considerations
          \                    likely increases     Higher radiation     hepatoblastoma\    age 35 years       for Further
          **Spine (thoracic,   risk, but the median dose to bowel\       Familial           \[whichever occurs Testing and
          lumbar, sacral)**    age of onset is not  Higher daily dose    polyposis\         last\]; more       Intervention**\
                               as well established  fraction\            Family history of  frequently if      \
                               as that of secondary Combined with        colorectal cancer  indicated based on Surgical and/or
                               breast cancer        chemotherapy         or polyps in first colonoscopy        oncology
                               following chest      (especially          degree relative    results; Per the   consultation as
                               radiation. The       alkylators)\                            ACS, begin         needed.
                               expert panel agreed  \                                       screening earlier  
                               that early onset of  **Medical                               for the following  
                               screening is likely  Conditions**\                           high-risk groups - 
                               beneficial, and that \                                       HNPCC: at puberty; 
                               a prudent course     Obesity\                                FAP: at age 21     
                               would be to initiate \                                       years; IBD: 8      
                               screening for        **Health                                years after        
                               colorectal cancer    Behaviors**\                            diagnosis of IBD;  
                               for those at highest \                                       Information from   
                               risk (abdominal,     High fat/low fiber                      the first          
                               pelvic, and/or       diet                                    colonoscopy will   
                               spinal radiation                                             inform frequency   
                               [\>]{.underline}30                                           of follow-up       
                               Gy) at age 35, or 10                                         testing)           
                               years post                                                                      
                               radiation, whichever                                                            
                               occurs last.                                                                    
                               Surveillance should                                                             
                               be done via                                                                     
                               colonoscopy as per                                                              
                               recommendations for                                                             
                               populations at                                                                  
                               highest risk, with                                                              
                               information from the                                                            
                               first colonoscopy                                                               
                               informing the                                                                   
                               frequency of                                                                    
                               follow-up testing.                                                              

  -------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Urinary Tract**

**System = Urinary\
Score = 1**

+---+--------+--------+--------------------+-------+-------+----------+
| * | *      | **Pot  | **Risk Factors**   | **Hi  | **Per | **Health |
| * | *Thera | ential |                    | ghest | iodic | Co       |
| S | peutic | Late   |                    | Risk  | Ev    | unseling |
| e | Agen   | Eff    |                    | Fact  | aluat | Further  |
| c | t(s)** | ects** |                    | ors** | ion** | Consider |
| \ |        |        |                    |       |       | ations** |
| # |        |        |                    |       |       |          |
| * |        |        |                    |       |       |          |
| * |        |        |                    |       |       |          |
+===+========+========+====================+=======+=======+==========+
| 7 | *      | *      | **Host Factors**\  | *     | **P   | **Health |
| 9 | *Whole | *Renal | \                  | *Trea | hysic | Links**\ |
|   | abdo   | toxic  | Bilateral Wilms    | tment | al**\ | \        |
|   | men**\ | ity**\ | tumor\             | Facto | \     | **See    |
|   | \      | \      | Mononephric\       | rs**\ | **    | \        |
|   | **All  | Renal  | \                  | \     | Blood | "Patient |
|   | upper  | in     | **Treatment        | Radi  | p     | Res      |
|   | abd    | suffic | Factors**\         | ation | ressu | ources\" |
|   | ominal | iency\ | \                  | dose  | re**\ | field**\ |
|   | fie    | Hypert | Radiomimetic       | [\>   | \     | \        |
|   | lds**\ | ension | chemotherapy       | ]{.un | (Yea  | Kidney   |
|   | \      |        | (e.g.,             | derli | rly)\ | Health\  |
|   | **     |        | doxorubicin,       | ne}15 | \     | See      |
|   | TBI**\ |        | dactinomycin)\     | Gy\   | **Sc  | also:    |
|   | \      |        | Radiation dose     | TBI   | reeni | Single   |
|   | **Info |        | [\>]{.underline}10 | [\    | ng**\ | Kidney   |
|   | L      |        | Gy\                | >]{.u | \     | Health\  |
|   | ink**: |        | TBI combined with  | nderl | **B   | \        |
|   | In     |        | radiation to the   | ine}6 | UN**\ | **Consid |
|   | cludes |        | kidney\            | Gy in | \     | erations |
|   | all    |        | Combined with      | s     | **Cre | for      |
|   | upper  |        | other nephrotoxic  | ingle | atini | Further  |
|   | abd    |        | agents such as:    | frac  | ne**\ | Testing  |
|   | ominal |        |                    | tion\ | \     | and      |
|   | fields |        | -   Cisplatin      | TBI   | **Na, | Interve  |
|   | [e     |        |                    | [\>   | K,    | ntion**\ |
|   | xcept] |        | -   Carboplatin    | ]{.un | Cl,   | \        |
|   | {.unde |        |                    | derli | CO~   | Ne       |
|   | rline} |        | -   Ifosfamide     | ne}12 | 2~**\ | phrology |
|   | Para   |        |                    | Gy    | \     | cons     |
|   | aortic |        | -                  | fr    | **Ca, | ultation |
|   |        |        |    Aminoglycosides | actio | Mg,   | for      |
|   |        |        |                    | nated | PO~   | patients |
|   |        |        | -   Amphotericin   |       | 4~**\ | with     |
|   |        |        |                    |       | \     | hyper    |
|   |        |        | -                  |       | (Bas  | tension, |
|   |        |        | Immunosuppressants |       | eline | prot     |
|   |        |        |                    |       | at    | einuria, |
|   |        |        | **Medical          |       | entry | or       |
|   |        |        | Conditions**\      |       | into  | pro      |
|   |        |        | \                  |       | long  | gressive |
|   |        |        | Diabetes mellitus\ |       | -term | renal    |
|   |        |        | Hypertension\      |       | foll  | insuf    |
|   |        |        | Nephrectomy        |       | owup. | ficiency |
|   |        |        |                    |       | If    |          |
|   |        |        |                    |       | abno  |          |
|   |        |        |                    |       | rmal, |          |
|   |        |        |                    |       | r     |          |
|   |        |        |                    |       | epeat |          |
|   |        |        |                    |       | as    |          |
|   |        |        |                    |       | clini |          |
|   |        |        |                    |       | cally |          |
|   |        |        |                    |       | in    |          |
|   |        |        |                    |       | dicat |          |
|   |        |        |                    |       | ed.)\ |          |
|   |        |        |                    |       | \     |          |
|   |        |        |                    |       | **Uri |          |
|   |        |        |                    |       | nalys |          |
|   |        |        |                    |       | is**\ |          |
|   |        |        |                    |       | \     |          |
|   |        |        |                    |       | (Ye   |          |
|   |        |        |                    |       | arly) |          |
+---+--------+--------+--------------------+-------+-------+----------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Urinary\
Score = 2A**

  ----------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential     **Risk Factors**      **Highest Risk     **Periodic        **Health Counseling
  \#**    Agent(s)**           Late Effects**                        Factors**          Evaluation**      Further
                                                                                                          Considerations**
  ------- -------------------- --------------- --------------------- ------------------ ----------------- --------------------
  80      [\>]{.underline}30   **Hemorrhagic   **Treatment           **Treatment        **History**\      **Health Links**\
          Gy to:\              cystitis**      Factors**\            Factors**\         \                 \
          \                                    \                     \                  **Hematuria**\    **See \"Patient
          **Whole abdomen\                     Higher radiation dose Combined with      \                 Resources\" field**\
          \                                    ([\>]{.underline}30   cyclophosphamide   **Urinary         \
          Pelvic\                              Gy to entire bladder; and/or ifosfamide  urgency/          Bladder Health\
          \                                    [\>]{.underline}60 Gy                    frequency**\      \
          Spine (sacral)**                     to portion of                            \                 **Counseling**\
                                               bladder)                                 **Urinary         \
                                                                                        incontinence/     Counsel to promptly
                                                                                        retention**\      report dysuria or
                                                                                        \                 gross hematuria\
                                                                                        **Dysuria**\      \
                                                                                        \                 **Considerations for
                                                                                        **Nocturia**\     Further Testing and
                                                                                        \                 Intervention**\
                                                                                        **Abnormal        \
                                                                                        urinary stream**\ Urine culture, spot
                                                                                        \                 urine
                                                                                        (Yearly)\         calcium/creatinine
                                                                                        \                 ratio, and
                                                                                        **Screening**\    ultrasound of
                                                                                        \                 kidneys and bladder
                                                                                        **Urinalysis**\   for patients with
                                                                                        \                 microscopic
                                                                                        (Yearly)          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](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Urinary\
Score = 1**

+---+--------+---------+------------------+-----+---------+----------+
| * | *      | **Po    | **Risk Factors** | **H | **P     | **Health |
| * | *Thera | tential |                  | igh | eriodic | Co       |
| S | peutic | Late    |                  | est | Evalu   | unseling |
| e | Agen   | Ef      |                  | R   | ation** | Further  |
| c | t(s)** | fects** |                  | isk |         | Consider |
| \ |        |         |                  | Fac |         | ations** |
| # |        |         |                  | tor |         |          |
| * |        |         |                  | s** |         |          |
| * |        |         |                  |     |         |          |
+===+========+=========+==================+=====+=========+==========+
| 8 | [\>]{. | **      | **Treatment      |     | **His   | **Health |
| 1 | underl | Urinary | Factors**\       |     | tory**\ | Links**\ |
|   | ine}30 | tract   | \                |     | \       | \        |
|   | Gy     | toxi    | Higher           |     | **Hemat | **See    |
|   | to:\   | city**\ | cumulative       |     | uria**\ | \        |
|   | \      | \       | radiation dose\  |     | \       | "Patient |
|   | *      | Bladder | ([\              |     | **      | Res      |
|   | *Whole | fi      | >]{.underline}45 |     | Urinary | ources\" |
|   | ab     | brosis\ | Gy)\             |     | u       | field**\ |
|   | domen\ | Dysfun  | Radiation to     |     | rgency/ | \        |
|   | \      | ctional | entire bladder\  |     | frequ   | Bladder  |
|   | P      | v       | Combined with:   |     | ency**\ | Health\  |
|   | elvic\ | oiding\ |                  |     | \       | \        |
|   | \      | Vesicou | -                |     | **      | **Consid |
|   | Spine  | reteral | Cyclophosphamide |     | Urinary | erations |
|   | (sac   | reflux\ |                  |     | incont  | for      |
|   | ral)** | Hydrone | -   Ifosfamide   |     | inence/ | Further  |
|   |        | phrosis |                  |     | reten   | Testing  |
|   |        |         | -   Vincristine  |     | tion**\ | and      |
|   |        |         |                  |     | \       | Interve  |
|   |        |         |                  |     | **Dys   | ntion**\ |
|   |        |         |                  |     | uria**\ | \        |
|   |        |         |                  |     | \       | Urologic |
|   |        |         |                  |     | **Noct  | cons     |
|   |        |         |                  |     | uria**\ | ultation |
|   |        |         |                  |     | \       | for      |
|   |        |         |                  |     | **A     | patients |
|   |        |         |                  |     | bnormal | with     |
|   |        |         |                  |     | urinary | inco     |
|   |        |         |                  |     | st      | ntinence |
|   |        |         |                  |     | ream**\ | or       |
|   |        |         |                  |     | \       | dysfu    |
|   |        |         |                  |     | (Y      | nctional |
|   |        |         |                  |     | early)\ | voiding. |
|   |        |         |                  |     | \       |          |
|   |        |         |                  |     | **Scree |          |
|   |        |         |                  |     | ning**\ |          |
|   |        |         |                  |     | \       |          |
|   |        |         |                  |     | *       |          |
|   |        |         |                  |     | *Urinal |          |
|   |        |         |                  |     | ysis**\ |          |
|   |        |         |                  |     | \       |          |
|   |        |         |                  |     | (       |          |
|   |        |         |                  |     | Yearly) |          |
+---+--------+---------+------------------+-----+---------+----------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = SMN\
Score = 2A**

+---+--------+--------+------------------+-----+---------+-----------+
| * | *      | **Pot  | **Risk Factors** | **H | **P     | **Health  |
| * | *Thera | ential |                  | igh | eriodic | C         |
| S | peutic | Late   |                  | est | Evalu   | ounseling |
| e | Agen   | Eff    |                  | R   | ation** | Further   |
| c | t(s)** | ects** |                  | isk |         | Conside   |
| \ |        |        |                  | Fac |         | rations** |
| # |        |        |                  | tor |         |           |
| * |        |        |                  | s** |         |           |
| * |        |        |                  |     |         |           |
+===+========+========+==================+=====+=========+===========+
| 8 | *      | **B    | **Treatment      |     | **His   | **Health  |
| 2 | *Whole | ladder | Factors**\       |     | tory**\ | Links**\  |
|   | ab     | malign | \                |     | \       | \         |
|   | domen\ | ancy** | Radiation to     |     | **Hemat | **See     |
|   | \      |        | pelvis\          |     | uria**\ | \"Patient |
|   | P      |        | Combined with:   |     | \       | Re        |
|   | elvic\ |        |                  |     | **      | sources\" |
|   | \      |        | -                |     | Urinary | field**\  |
|   | Spine  |        | Cyclophosphamide |     | u       | \         |
|   | (sacr  |        |                  |     | rgency/ | Bladder   |
|   | al)**\ |        | -   Ifosfamide   |     | frequ   | Health\   |
|   | \      |        |                  |     | ency**\ | \         |
|   | **Info |        | **Health         |     | \       | **Coun    |
|   | L      |        | Behaviors**\     |     | **      | seling**\ |
|   | ink**: |        | \                |     | Urinary | \         |
|   | A      |        | Alcohol use\     |     | incont  | Counsel   |
|   | pplies |        | Smoking          |     | inence/ | to        |
|   | to     |        |                  |     | reten   | promptly  |
|   | sacral |        |                  |     | tion**\ | report    |
|   | spine  |        |                  |     | \       | dysuria   |
|   | at     |        |                  |     | **Dys   | or gross  |
|   | doses  |        |                  |     | uria**\ | h         |
|   | [\>]{. |        |                  |     | \       | ematuria\ |
|   | underl |        |                  |     | **Noct  | \         |
|   | ine}30 |        |                  |     | uria**\ | **Consi   |
|   | Gy     |        |                  |     | \       | derations |
|   | only.  |        |                  |     | **A     | for       |
|   |        |        |                  |     | bnormal | Further   |
|   |        |        |                  |     | urinary | Testing   |
|   |        |        |                  |     | st      | and       |
|   |        |        |                  |     | ream**\ | Interv    |
|   |        |        |                  |     | \       | ention**\ |
|   |        |        |                  |     | (Y      | \         |
|   |        |        |                  |     | early)\ | Urine     |
|   |        |        |                  |     | \       | culture,  |
|   |        |        |                  |     | **Scree | spot      |
|   |        |        |                  |     | ning**\ | urine     |
|   |        |        |                  |     | \       | calcium/c |
|   |        |        |                  |     | *       | reatinine |
|   |        |        |                  |     | *Urinal | ratio,    |
|   |        |        |                  |     | ysis**\ | and       |
|   |        |        |                  |     | \       | u         |
|   |        |        |                  |     | (       | ltrasound |
|   |        |        |                  |     | Yearly) | of        |
|   |        |        |                  |     |         | kidneys   |
|   |        |        |                  |     |         | and       |
|   |        |        |                  |     |         | bladder   |
|   |        |        |                  |     |         | for       |
|   |        |        |                  |     |         | patients  |
|   |        |        |                  |     |         | with      |
|   |        |        |                  |     |         | mi        |
|   |        |        |                  |     |         | croscopic |
|   |        |        |                  |     |         | hematuria |
|   |        |        |                  |     |         | (defined  |
|   |        |        |                  |     |         | as        |
|   |        |        |                  |     |         | [\>]{.un  |
|   |        |        |                  |     |         | derline}5 |
|   |        |        |                  |     |         | RBC/HPF   |
|   |        |        |                  |     |         | on at     |
|   |        |        |                  |     |         | least 2   |
|   |        |        |                  |     |         | oc        |
|   |        |        |                  |     |         | casions). |
|   |        |        |                  |     |         | N         |
|   |        |        |                  |     |         | ephrology |
|   |        |        |                  |     |         | or        |
|   |        |        |                  |     |         | Urology   |
|   |        |        |                  |     |         | referral  |
|   |        |        |                  |     |         | for       |
|   |        |        |                  |     |         | patients  |
|   |        |        |                  |     |         | with      |
|   |        |        |                  |     |         | culture   |
|   |        |        |                  |     |         | -negative |
|   |        |        |                  |     |         | mi        |
|   |        |        |                  |     |         | croscopic |
|   |        |        |                  |     |         | hematuria |
|   |        |        |                  |     |         | AND       |
|   |        |        |                  |     |         | abnormal  |
|   |        |        |                  |     |         | u         |
|   |        |        |                  |     |         | ltrasound |
|   |        |        |                  |     |         | and/or    |
|   |        |        |                  |     |         | abnormal  |
|   |        |        |                  |     |         | calcium/c |
|   |        |        |                  |     |         | reatinine |
|   |        |        |                  |     |         | ratio.    |
|   |        |        |                  |     |         | Urology   |
|   |        |        |                  |     |         | referral  |
|   |        |        |                  |     |         | for       |
|   |        |        |                  |     |         | patients  |
|   |        |        |                  |     |         | with      |
|   |        |        |                  |     |         | culture   |
|   |        |        |                  |     |         | negative  |
|   |        |        |                  |     |         | ma        |
|   |        |        |                  |     |         | croscopic |
|   |        |        |                  |     |         | h         |
|   |        |        |                  |     |         | ematuria. |
+---+--------+--------+------------------+-----+---------+-----------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Female Reproductive System**

**System = Female reproductive\
Score = 2B**

  ------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec \#** **Therapeutic        **Potential Late   **Risk        **Highest Risk       **Periodic       **Health Counseling Further Considerations**
             Agent(s)**           Effects**          Factors**     Factors**            Evaluation**     
  ---------- -------------------- ------------------ ------------- -------------------- ---------------- -----------------------------------------------------
  83\        **Whole abdomen**\   **Uterine vascular **Host        **Host Factors**\    **History**\     **Health Links**\
  \          \                    insufficiency**\   Factors**\    \                    \                \
  (Female)   **Pelvic**\          (resulting in      \             Prepubertal at       **Pregnancy**\   **See \"Patient Resources\" field**\
             \                    adverse pregnancy  Females with  treatment\           \                \
             **Spine (lumbar,     outcomes, such as  Wilms tumor   \                    **Childbirth     Female Health Issues\
             sacral)**\           spontaneous        and           **Treatment          history**\       \
             \                    abortion, neonatal associated    Factors**\           \                **Resources**\
             **TBI**\             death, low-birth   müllerian     \                    (Yearly and as   \
             \                    weight infant,     anomalies\    Radiation dose       clinically       American Society for Reproductive Medicine:
             **Info Link**:       fetal malposition, \             [\>]{.underline}30   indicated)       [www.asrm.org](http://www.asrm.org/)\
             Applies to all       and premature      **Treatment   Gy\                                   Fertile Hope:
             pelvic fields except labor)\            Factors**\    TBI                                   [www.fertilehope.org](http://www.fertilehope.org/)\
             iliac/inguinal.      \                  \                                                   \
             Applies to lumbar    **Info Link**: 10% Higher                                              **Considerations for Further Testing and
             and sacral spine at  of girls with      radiation                                           Intervention**\
             doses                Wilms tumor have   dose to                                             \
             [\>]{.underline}25   congenital uterine pelvis                                              Consider high-level ultrasound evaluation of
             Gy.                  anomalies.                                                             genitourinary tract after pubertal development as
                                                                                                         clinically indicated in patients contemplating
                                                                                                         pregnancy. High-risk obstetrical care during
                                                                                                         pregnancy.

  ------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Female reproductive\
Score = 1**

  -------------------------------------------------------------------------------------------------------------------------------------------------------------------
  **Sec \#** **Therapeutic        **Potential Late   **Risk Factors**     **Highest Risk       **Periodic       **Health Counseling Further Considerations**
             Agent(s)**           Effects**                               Factors**            Evaluation**     
  ---------- -------------------- ------------------ -------------------- -------------------- ---------------- -----------------------------------------------------
  84\        **Whole abdomen**\   **Gonadal          **Host Factors**\    **Treatment          **History**\     **Health Links**\
  \          \                    dysfunction        \                    Factors**\           \                \
  (Female)   **Pelvic**\          (ovarian)**\       Older age at         \                    **Pubertal       **See \"Patient Resources\" field**\
             \                    \                  irradiation\         Prepubertal female:  (onset,          \
             **Spine (lumbar,     Delayed/arrested   \                    Radiation dose       tempo)**\        Female Health Issues\
             sacral)**\           puberty\           **Treatment          [\>]{.underline}15   \                \
             \                    Premature          Factors**\           Gy\                  **Menstrual/     **Resources**\
             **TBI**\             menopause\         \                    Pubertal female:     pregnancy        \
             \                    Infertility        Prepubertal female:  Radiation dose       history**\       American Society for Reproductive Medicine:
             **Info Link**:                          Radiation dose       [\>]{.underline}10   \                [www.asrm.org](http://www.asrm.org/)\
             Applies to lumbar                       [\>]{.underline}10   Gy\                  **Sexual         Fertile Hope:
             and sacral spine at                     Gy\                  Combined with        function         [www.fertilehope.org](http://www.fertilehope.org/)\
             doses                                   Pubertal female:     cyclophosphamide     (vaginal         \
             [\>]{.underline}25                      Radiation dose       conditioning for HCT dryness,         **Counseling**\
             Gy only.                                [\>]{.underline}5                         libido)**\       \
                                                     Gy\                                       \                Counsel regarding the need for contraception, since
                                                     Combined with                             **Medication use there is tremendous individual variability in gonadal
                                                     alkylating agent                          impacting sexual toxicity after exposure to radiation. Recovery of
                                                     chemotherapy\                             function**\      fertility may occur years after therapy. Counsel
                                                     Longer time since                         \                regarding risks and benefits of HRT.\
                                                     treatment                                 (Yearly)\        \
                                                                                               \                **Considerations for Further Testing and
                                                                                               **Physical**\    Intervention**\
                                                                                               \                \
                                                                                               **Tanner         Refer to endocrinologist for delayed/arrested puberty
                                                                                               stage**\         or persistently abnormal hormone levels. Gynecology
                                                                                               \                or endocrinology consultation for HRT. Consider
                                                                                               (Yearly until    evaluation for conditions exacerbated by hypogonadism
                                                                                               sexually         (e.g., osteopenia/osteoporosis). Reproductive
                                                                                               mature)\         endocrinology consultation for infertile couples
                                                                                               \                interested in assisted reproductive technologies.
                                                                                               **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)      

  -------------------------------------------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Female reproductive\
Score = 2A**

  --------------------------------------------------------------------------------------------------------------------------------
  **Sec \#** **Therapeutic   **Potential Late      **Risk Factors**     **Highest Risk       **Periodic         **Health
             Agent(s)**      Effects**                                  Factors**            Evaluation**       Counseling Further
                                                                                                                Considerations**
  ---------- --------------- --------------------- -------------------- -------------------- ------------------ ------------------
  85\        **Pelvic**      **Vaginal             **Host Factors**\    **Treatment          **History**\       **Considerations
  \                          fibrosis/stenosis**   \                    Factors**\           \                  for Further
  (Female)                                         Vaginal tumor or     \                    **Psychosocial     Testing and
                                                   pelvic tumor         Prepubertal female:  assessment**\      Intervention**\
                                                   adjacent to vagina\  Radiation dose       \                  \
                                                   \                    [\>]{.underline}35   **Dyspareunia**\   Gynecologic
                                                   **Treatment          Gy\                  \                  consultation for
                                                   Factors**\           Postpubertal female: **Vulvar pain**\   management.
                                                   Prepubertal female:  Radiation dose       \                  Psychological
                                                   Radiation dose       [\>]{.underline}55   **Post-coital      consultation in
                                                   [\>]{.underline}25   Gy                   bleeding**\        patients with
                                                   Gy\                                       \                  emotional
                                                   Postpubertal female:                      **Difficulty with  difficulties.
                                                   Radiation dose                            tampon             
                                                   [\>]{.underline}50                        insertion**\       
                                                   Gy\                                       \                  
                                                   \                                         (Yearly)           
                                                   **Medical                                                    
                                                   Conditions**\                                                
                                                   \                                                            
                                                   Chronic GVHD                                                 

  --------------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Male Reproductive System**

**System = Male reproductive\
Score = 1**

+----+--------+--------+----------+--------+-----------+-------------+
| *  | *      | **Pot  | **Risk   | **H    | *         | **Health    |
| *S | *Thera | ential | F        | ighest | *Periodic | Counseling  |
| ec | peutic | Late   | actors** | Risk   | Eva       | Further     |
| \# | Agen   | Eff    |          | Fac    | luation** | Consi       |
| ** | t(s)** | ects** |          | tors** |           | derations** |
+====+========+========+==========+========+===========+=============+
| 8  | **P    | **G    | **T      | **Tre  | **Scr     | **Health    |
| 6\ | elvic\ | onadal | reatment | atment | eening**\ | Links**\    |
| \  | \      | dysfu  | Fa       | Fact   | \         | \           |
| (M | Testi  | nction | ctors**\ | ors**\ | **Semen   | **See       |
| al | cular\ | (tes   | \        | \      | an        | \"Patient   |
| e) | \      | ticula | R        | Rad    | alysis**\ | Resources\" |
|    | TBI**  | r):**\ | adiation | iation | \         | field**\    |
|    |        | \      | dose to  | dose   | (As       | \           |
|    |        | **Germ | testes:  | to     | requested | Male Health |
|    |        | cell   |          | testes | by        | Issues\     |
|    |        | fail   | -   1 to | [\>]{  | patient   | \           |
|    |        | ure**\ |     3    | .under | and for   | **R         |
|    |        | \      |     Gy:  | line}6 | e         | esources**\ |
|    |        | O      |     Azo  | Gy:    | valuation | \           |
|    |        | ligosp | ospermia | Azoos  | of        | American    |
|    |        | ermia\ |     may  | permia | inf       | Society for |
|    |        | Azoosp |     be   | likely | ertility. | R           |
|    |        | ermia\ |     re   | per    | Periodic  | eproductive |
|    |        | Infer  | versible | manent | e         | Medicine:   |
|    |        | tility |          |        | valuation | [www        |
|    |        |        | -   3 to |        | over time | .asrm.org]( |
|    |        |        |     6    |        | is        | http://www. |
|    |        |        |     Gy:  |        | re        | asrm.org/)\ |
|    |        |        |     Azo  |        | commended | Fertile     |
|    |        |        | ospermia |        | as        | Hope:       |
|    |        |        |          |        | r         | [www.fe     |
|    |        |        | possibly |        | esumption | rtilehope.o |
|    |        |        |     re   |        | of        | rg](http:// |
|    |        |        | versible |        | sperma    | www.fertile |
|    |        |        |     (but |        | togenesis | hope.org/)\ |
|    |        |        |     u    |        | can occur | \           |
|    |        |        | nlikely) |        | up to 10  | **Co        |
|    |        |        |          |        | years     | unseling**\ |
|    |        |        |          |        | post      | \           |
|    |        |        |          |        | therapy.) | Counsel     |
|    |        |        |          |        |           | regarding   |
|    |        |        |          |        |           | the need    |
|    |        |        |          |        |           | for         |
|    |        |        |          |        |           | con         |
|    |        |        |          |        |           | traception, |
|    |        |        |          |        |           | since there |
|    |        |        |          |        |           | is          |
|    |        |        |          |        |           | tremendous  |
|    |        |        |          |        |           | individual  |
|    |        |        |          |        |           | variability |
|    |        |        |          |        |           | in gonadal  |
|    |        |        |          |        |           | toxicity    |
|    |        |        |          |        |           | after       |
|    |        |        |          |        |           | exposure to |
|    |        |        |          |        |           | radiation.  |
|    |        |        |          |        |           | Recovery of |
|    |        |        |          |        |           | fertility   |
|    |        |        |          |        |           | may occur   |
|    |        |        |          |        |           | years after |
|    |        |        |          |        |           | therapy.\   |
|    |        |        |          |        |           | \           |
|    |        |        |          |        |           | **Con       |
|    |        |        |          |        |           | siderations |
|    |        |        |          |        |           | for Further |
|    |        |        |          |        |           | Testing and |
|    |        |        |          |        |           | Inte        |
|    |        |        |          |        |           | rvention**\ |
|    |        |        |          |        |           | \           |
|    |        |        |          |        |           | R           |
|    |        |        |          |        |           | eproductive |
|    |        |        |          |        |           | en          |
|    |        |        |          |        |           | docrinology |
|    |        |        |          |        |           | c           |
|    |        |        |          |        |           | onsultation |
|    |        |        |          |        |           | for         |
|    |        |        |          |        |           | infertile   |
|    |        |        |          |        |           | couples     |
|    |        |        |          |        |           | interested  |
|    |        |        |          |        |           | in assisted |
|    |        |        |          |        |           | r           |
|    |        |        |          |        |           | eproductive |
|    |        |        |          |        |           | te          |
|    |        |        |          |        |           | chnologies. |
|    |        |        |          |        |           | Testing for |
|    |        |        |          |        |           | Inhibin B   |
|    |        |        |          |        |           | can be      |
|    |        |        |          |        |           | considered  |
|    |        |        |          |        |           | in          |
|    |        |        |          |        |           | conjunction |
|    |        |        |          |        |           | with FSH as |
|    |        |        |          |        |           | an          |
|    |        |        |          |        |           | indicator   |
|    |        |        |          |        |           | of germ     |
|    |        |        |          |        |           | cell        |
|    |        |        |          |        |           | function.   |
+----+--------+--------+----------+--------+-----------+-------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Male reproductive\
Score = 1**

+---+-------+---------+------+----------------+--------+--------------+
| * | **T   | **Po    | **   | **Highest Risk | **Pe   | **Health     |
| * | herap | tential | Risk | Factors**      | riodic | Counseling   |
| S | eutic | Late    | F    |                | Evalua | Further      |
| e | Agent | Ef      | acto |                | tion** | Cons         |
| c | (s)** | fects** | rs** |                |        | iderations** |
| \ |       |         |      |                |        |              |
| # |       |         |      |                |        |              |
| * |       |         |      |                |        |              |
| * |       |         |      |                |        |              |
+===+=======+=========+======+================+========+==============+
| 8 | [\>   | **      | **T  | **Treatment    | **Hist | **Health     |
| 7 | ]{.un | Gonadal | reat | Factors**\     | ory**\ | Links**\     |
| \ | derli | dysf    | ment | \              | \      | \            |
| \ | ne}20 | unction | Fa   | Combined with: | **Pu   | **See        |
| ( | Gy    | (t      | ctor |                | bertal | \"Patient    |
| M | to:\  | esticul | s**\ | -   Alkylating | (      | Resources\"  |
| a | \     | ar):**\ | \    |     agents     | onset, | field**\     |
| l | **Pe  | \       | Te   |                | tem    | \            |
| e | lvic\ | *       | stic | -   Cy         | po)**\ | Male Health  |
| ) | Te    | *Leydig | ular | clophosphamide | \      | Issues\      |
|   | sticu | cell    | irr  |                | **     | \            |
|   | lar** | dysfunc | adia |   conditioning | Sexual | **           |
|   |       | tion**\ | tion |     for HCT    | fu     | Resources**\ |
|   |       | \       | comb |                | nction | \            |
|   |       | De      | ined |                | (erec  | American     |
|   |       | layed/a | with |                | tions, | Society for  |
|   |       | rrested | he   |                | noc    | Reproductive |
|   |       | p       | ad/b |                | turnal | Medicine:    |
|   |       | uberty\ | rain |                | emis   | [            |
|   |       | Hypog   | irr  |                | sions, | www.asrm.org |
|   |       | onadism | adia |                | libi   | ](http://www |
|   |       |         | tion |                | do)**\ | .asrm.org/)\ |
|   |       |         |      |                | \      | Fertile      |
|   |       |         |      |                | **Medi | Hope:        |
|   |       |         |      |                | cation | [ww          |
|   |       |         |      |                | use    | w.fertilehop |
|   |       |         |      |                | imp    | e.org](http: |
|   |       |         |      |                | acting | //www.fertil |
|   |       |         |      |                | sexual | ehope.org/)\ |
|   |       |         |      |                | funct  | \            |
|   |       |         |      |                | ion**\ | **Co         |
|   |       |         |      |                | \      | nsiderations |
|   |       |         |      |                | (Ye    | for Further  |
|   |       |         |      |                | arly)\ | Testing and  |
|   |       |         |      |                | \      | Int          |
|   |       |         |      |                | *      | ervention**\ |
|   |       |         |      |                | *Physi | \            |
|   |       |         |      |                | cal**\ | Refer to     |
|   |       |         |      |                | \      | end          |
|   |       |         |      |                | **     | ocrinologist |
|   |       |         |      |                | Tanner | for delayed  |
|   |       |         |      |                | st     | puberty or   |
|   |       |         |      |                | age**\ | persistently |
|   |       |         |      |                | \      | abnormal     |
|   |       |         |      |                | **Test | hormone      |
|   |       |         |      |                | icular | levels.      |
|   |       |         |      |                | volume | Urology or   |
|   |       |         |      |                | by     | e            |
|   |       |         |      |                | Prader | ndocrinology |
|   |       |         |      |                | orc    | consultation |
|   |       |         |      |                | hidome | for HRT.     |
|   |       |         |      |                | try**\ | Consider     |
|   |       |         |      |                | \      | evaluation   |
|   |       |         |      |                | (      | for          |
|   |       |         |      |                | Yearly | conditions   |
|   |       |         |      |                | until  | exacerbated  |
|   |       |         |      |                | se     | by           |
|   |       |         |      |                | xually | hypogonadism |
|   |       |         |      |                | ma     | (e.g.,       |
|   |       |         |      |                | ture)\ | o            |
|   |       |         |      |                | \      | steopenia/os |
|   |       |         |      |                | **     | teoporosis). |
|   |       |         |      |                | Screen |              |
|   |       |         |      |                | ing**\ |              |
|   |       |         |      |                | \      |              |
|   |       |         |      |                | **FSH, |              |
|   |       |         |      |                | LH,    |              |
|   |       |         |      |                | tes    |              |
|   |       |         |      |                | toster |              |
|   |       |         |      |                | one**\ |              |
|   |       |         |      |                | \      |              |
|   |       |         |      |                | (Ba    |              |
|   |       |         |      |                | seline |              |
|   |       |         |      |                | at age |              |
|   |       |         |      |                | 14,    |              |
|   |       |         |      |                | and as |              |
|   |       |         |      |                | clin   |              |
|   |       |         |      |                | ically |              |
|   |       |         |      |                | ind    |              |
|   |       |         |      |                | icated |              |
|   |       |         |      |                | in     |              |
|   |       |         |      |                | pa     |              |
|   |       |         |      |                | tients |              |
|   |       |         |      |                | with   |              |
|   |       |         |      |                | d      |              |
|   |       |         |      |                | elayed |              |
|   |       |         |      |                | p      |              |
|   |       |         |      |                | uberty |              |
|   |       |         |      |                | or     |              |
|   |       |         |      |                | cl     |              |
|   |       |         |      |                | inical |              |
|   |       |         |      |                | signs  |              |
|   |       |         |      |                | and    |              |
|   |       |         |      |                | sy     |              |
|   |       |         |      |                | mptoms |              |
|   |       |         |      |                | of     |              |
|   |       |         |      |                | testos |              |
|   |       |         |      |                | terone |              |
|   |       |         |      |                | defic  |              |
|   |       |         |      |                | iency) |              |
+---+-------+---------+------+----------------+--------+--------------+

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**Potential Impact to Musculoskeletal System**

**System = Musculoskeletal\
Score = 1**

  ---------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late    **Risk        **Highest Risk       **Periodic     **Health
  \#**    Agent(s)**           Effects**           Factors**     Factors**            Evaluation**   Counseling Further
                                                                                                     Considerations**
  ------- -------------------- ------------------- ------------- -------------------- -------------- ------------------
  88      **All neck fields**\ **Musculoskeletal   **Host        **Host Factors**\    **History**\   **Counseling**\
          \                    growth problems**\  Factors**\    \                    \              \
          **All chest          \                   \             Prepubertal at       **Height**\    Counsel regarding
          fields**\            Hypoplasia\         Younger age   treatment\           \              increased risk of
          \                    Fibrosis\           at treatment\ \                    **Weight**\    fractures in
          **Whole abdomen**\   Reduced or uneven   \             **Treatment          \              weight-bearing
          \                    growth\             **Treatment   Factors**\           (Yearly)\      irradiated bones\
          **All upper          Shortened trunk     Factors**\    \                    \              \
          abdominal fields**\  height (trunk       \             Epiphysis in         **Sitting      **Considerations
          \                    radiation)\         Higher        treatment field\     height**\      for Further
          **All extremity      Limb length         cumulative    Dose                 \              Testing and
          fields**\            discrepancy         radiation     [\>]{.underline}20   (Yearly for    Intervention**\
          \                    (extremity          dose\         Gy\                  patients who   \
          **Pelvic**\          radiation)          Larger        Orthovoltage         had trunk      Orthopedic
          \                                        radiation     radiation (commonly  radiation)\    consultation for
          **All spinal                             treatment     used before 1970)    \              any deficit noted
          fields**\                                field\        due to delivery of   **Limb         in growing child.
          \                                        Higher        greater dose to skin lengths**\     Consider plastic
          **Info Link**:                           radiation     and bones            \              surgery consult
          Applies to spine at                      dose per                           (Yearly for    for
          doses                                    fraction                           patients who   reconstruction.
          [\>]{.underline}12                                                          had extremity  
          Gy only.                                                                    radiation)     

  ---------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Musculoskeletal\
Score = 1**

  --------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential     **Risk          **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**           Late Effects**  Factors**       Factors**            Evaluation**    Counseling Further
                                                                                                    Considerations**
  ------- -------------------- --------------- --------------- -------------------- --------------- ------------------
  89      **Mantle\            **Scoliosis**   **Host          **Treatment          **Physical**\   **Health Links**\
          Mini-Mantle\                         Factors**\      Factors**\           \               \
          Mediastinal\                         \               \                    **Spine exam    **See \"Patient
          Whole lung\                          Younger age at  Radiation doses      for             Resources\"
          Chest (thorax)\                      irradiation\    [\>]{.underline}20   scoliosis**\    field**\
          Whole abdomen**\                     Paraspinal      Gy (lower doses for  \               \
          \                                    malignancies\   infants)\            (Yearly until   Scoliosis and
          **All upper                          \               Orthovoltage         growth          Kyphosis\
          abdominal fields**\                  **Treatment     radiation (commonly  completed. May  \
          \                                    Factors**\      used before 1970)    need more       **Considerations
          **Pelvic**\                          \               due to delivery of   frequent        for Further
          \                                    Hemithoracic or greater dose to skin assessment      Testing and
          **Spine (lumbar,                     abdominal       and bones            during          Intervention**\
          sacral, thoracic)**\                 radiation\                           puberty.)       \
          \                                    Hemithoracic,                                        Spine films in
          **Info Link**:                       abdominal or                                         patients with
          Applies to spine at                  spinal surgery\                                      clinically
          doses                                Radiation of                                         apparent curve.
          [\>]{.underline}12                   only a portion                                       Orthopedic
          Gy only.                             of (rather than                                      consultation as
                                               whole)                                               indicated based on
                                               vertebral body\                                      radiographic exam.
                                               \                                                    
                                               **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                                                

  --------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Musculoskeletal\
Score = 1**

  -----------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential    **Risk Factors**    **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**           Late Effects**                     Factors**            Evaluation**    Counseling Further
                                                                                                       Considerations**
  ------- -------------------- -------------- ------------------- -------------------- --------------- ------------------
  90      **Mantle\            **Kyphosis**   **Host Factors**\   **Treatment          **Physical**\   **Health Links**\
          Mini-Mantle\                        \                   Factors**\           \               \
          Mediastinal\                        Younger age at      \                    **Spine exam    **See \"Patient
          Whole lung\                         irradiation\        Radiation doses      for kyphosis**\ Resources\"
          Chest (thorax)\                     Paraspinal          [\>]{.underline}20   \               field**\
          Whole abdomen**\                    malignancies\       Gy (lower doses for  (Yearly until   \
          \                                   Neurofibromatosis   infants)\            growth          Scoliosis and
          **All upper                                             Orthovoltage         completed. May  Kyphosis\
          abdominal fields**\                                     radiation (commonly  need more       \
          \                                                       used before 1970)    frequent        **Considerations
          **Spine                                                 due to delivery of   assessment      for Further
          (thoracic)**\                                           greater dose to skin during          Testing and
          \                                                       and bones            puberty.)       Intervention**\
          **Info Link**:                                                                               \
          Applies to thoracic                                                                          Spine films in
          spine at doses                                                                               patients with
          [\>]{.underline}30                                                                           clinically
          Gy only.                                                                                     apparent curve.
                                                                                                       Orthopedic
                                                                                                       consultation as
                                                                                                       indicated based on
                                                                                                       radiographic exam.

  -----------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

**System = Musculoskeletal\
Score = 1**

  ------------------------------------------------------------------------------------------------------------------------
  **Sec   **Therapeutic        **Potential Late      **Risk        **Highest Risk       **Periodic      **Health
  \#**    Agent(s)**           Effects**             Factors**     Factors**            Evaluation**    Counseling Further
                                                                                                        Considerations**
  ------- -------------------- --------------------- ------------- -------------------- --------------- ------------------
  91      [\>]{.underline}40   **Radiation-induced   **Treatment   **Treatment          **Physical**\   **Considerations
          Gy to:\              fracture**            Factors**\    Factors**\           \               for Further
          \                                          \             \                    **Pain,         Testing and
          **All neck fields**\                       History of    Radiation doses      swelling,       Intervention**\
          \                                          surgery to    [\>]{.underline}50   deformity of    \
          **All chest                                cortex of     Gy to bone           bone** (As      Radiograph of
          fields**\                                  bone                               Indicated)      affected bone as
          \                                                                                             clinically
          **Whole abdomen**\                                                                            indicated.
          \                                                                                             Orthopedic
          **All upper                                                                                   evaluation as
          abdominal fields**\                                                                           clinically
          \                                                                                             indicated.
          **Pelvic**\                                                                                   
          \                                                                                             
          **All spinal                                                                                  
          fields**\                                                                                     
          \                                                                                             
          **All extremity                                                                               
          fields**                                                                                      

  ------------------------------------------------------------------------------------------------------------------------

**Note**: See a list of [Abbreviations](#Abbreviations) at the end of
the \"Major Recommendations\" field.

[]{#Abbreviations .anchor}**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

-   CO~2~, 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

-   PO~4~, 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.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

Although several well-conducted studies on large populations of
childhood cancer survivors have demonstrated associations between
specific exposures and late effects, the size of the survivor population
and the rate of occurrence of late effects does not allow for clinical
studies that would assess the impact of screening recommendations on the
morbidity and mortality associated with the late effect. Therefore,
scoring of each exposure reflects the expert panel\'s assessment of the
level of literature support linking the therapeutic exposure with the
late effect coupled with an assessment of the appropriateness of the
recommended screening modality in identifying the potential late effect
based on the panel\'s collective clinical experience.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Potential benefits of implementing these guidelines into clinical
practice include earlier identification of and intervention for late
onset therapy-related complications in this at-risk population,
potentially reducing or ameliorating the impact of late complications on
the health status of survivors. In addition, ongoing healthcare that
promotes healthy lifestyle choices and provides ongoing monitoring of
health status is important for all cancer survivors.

#### POTENTIAL HARMS

Potential harms of guideline implementation include increased patient
anxiety related to enhanced awareness of possible complications, as well
as the potential for false-positive screening evaluations, leading to
unnecessary further workup. In addition, costs of long-term follow-up
care may be prohibitive for some patients, particularly those lacking
health insurance, or those with insurance that does not cover the
recommended screening evaluations.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   The information and contents of each document or series of documents
    made available by the Children\'s Oncology Group relating to late
    effects of cancer treatment and care or containing the title
    \"Long-Term Follow-Up Guidelines for Survivors of Childhood,
    Adolescent, and Young Adult Cancers\" or the title \"Health Link,\"
    whether available in print or electronic format (including any
    digital format, e-mail transmission, or download from the website),
    shall be known hereinafter as \"Informational Content.\" All
    Informational Content is for informational purpose only. The
    Informational Content is not intended to substitute for medical
    advice, medical care, diagnosis, or treatment obtained from a
    physician or healthcare provider.

-   *To cancer patients (if children, their parents or legal
    guardians)*: Please seek the advice of a physician or other
    qualified healthcare provider with any questions you may have
    regarding a medical condition and do not rely on the Informational
    Content. The Children\'s Oncology Group is a research organization
    and does not provide individualized medical care or treatment.

-   *To physicians and other healthcare providers*: The Informational
    Content is not intended to replace your independent clinical
    judgment, medical advice, or to exclude other legitimate criteria
    for screening, health counseling, or intervention for specific
    complications of childhood cancer treatment. Neither is the
    Informational Content intended to exclude other reasonable
    alternative follow-up procedures. The Informational Content is
    provided as a courtesy, but not intended as a sole source of
    guidance in the evaluation of childhood cancer survivors. The
    Children\'s Oncology Group recognizes that specific patient care
    decisions are the prerogative of the patient, family, and healthcare
    provider.

-   While the Children\'s Oncology Group has made every attempt to
    assure that the Informational Content is accurate and complete as of
    the date of publication, no warranty or representation, express or
    implied, is made as to the accuracy, reliability, completeness,
    relevance, or timeliness of such Informational Content.

-   No liability is assumed by the Children\'s Oncology Group or any
    affiliated party or member thereof for damage resulting from the
    use, review, or access of the Informational Content. You agree to
    the following terms of indemnification: (i) \"Indemnified Parties\"
    include authors and contributors to the Informational Content, all
    officers, directors, representatives, employees, agents, and members
    of the Children\'s Oncology Group and affiliated organizations; (ii)
    by using, reviewing, or accessing the Informational Content, you
    agree, at your own expense, to indemnify, defend and hold harmless
    Indemnified Parties from any and all losses, liabilities, or damages
    (including attorneys\' fees and costs) resulting from any and all
    claims, causes of action, suits, proceedings, or demands related to
    or arising out of use, review or access of the Informational
    Content.

-   Ultimately, as with all clinical guidelines, decisions regarding
    screening and clinical management for any specific patient should be
    individually tailored, taking into consideration the patient\'s
    treatment history, risk factors, co-morbidities, and lifestyle.
    These guidelines are therefore not intended to replace clinical
    judgment or to exclude other reasonable alternative follow-up
    procedures. The Children\'s Oncology Group recognizes that specific
    patient care decisions are the prerogative of the patient, family,
    and healthcare provider.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Implementation of these guidelines is intended to standardize and
enhance follow-up care provided to survivors of pediatric malignancies
throughout the lifespan. Considerations in this regard include the
practicality and efficiency of applying these broad guidelines in
individual clinical situations. Studies to address guideline
implementation and refinement are a top priority of the Children\'s
Oncology Group (COG) Late Effects Committee, and proposals to study
feasibility of guideline use in limited institutions are currently
underway. Issues to be addressed include description of anticipated
barriers to application of the recommendations in the guidelines and
development of review criteria for measuring changes in care when the
guidelines are implemented. Additional concerns surround the lack of
current evidence establishing the efficacy of screening for late
complications in pediatric cancer survivors. While most clinicians
believe that ongoing surveillance for these late complications is
important in order to allow for early detection and intervention for
complications that may arise, development of studies addressing the
efficacy of this approach is imperative in order to determine which
screening modalities are optimal for asymptomatic survivors.

In addition, the clinical utility of this lengthy document has also been
a top concern of the COG Late Effects Committee. While recognizing that
the length and depth of these guidelines is important in order to
provide clinically-relevant, evidence-based recommendations and
supporting health education materials, clinician time limitations and
the effort required to identify the specific recommendations relevant to
individual patients have been identified as barriers to their clinical
application. Therefore, the COG Late Effects Committee is currently
partnering with the Baylor School of Medicine in order to develop a
web-based interface, known as \"Passport for Care,\" that will generate
individualized exposure-based recommendations from these guidelines in a
clinician-focused format for ease of patient-specific application of the
guidelines in the clinical setting. As additional information regarding
implementation of the Passport for Care web-based interface becomes
available, updates will be posted at
[www.survivorshipguidelines.org](http://www.survivorshipguidelines.org/).

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Patient Resources\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Children\'s Oncology Group. Long-term follow-up guidelines for survivors
of childhood, adolescent, and young adult cancers. Sections 38-91:
radiation. Bethesda (MD): Children\'s Oncology Group; 2006 Mar. 74 p.
\[360 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Sep (revised 2006 Mar)

#### GUIDELINE DEVELOPER(S)

Children\'s Oncology Group - Medical Specialty Society

#### SOURCE(S) OF FUNDING

This work was supported by the Children\'s Oncology Group grant U10
CA098543 from the National Cancer Institute.

#### GUIDELINE COMMITTEE

Children\'s Oncology Group Nursing Discipline and Late Effects Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Melissa M. Hudson, MD\
Vice-Chair -- COG Late Effects Committee\
Member, Department of Hematology-Oncology\
Director, After Completion of Therapy Clinic\
St. Jude Children\'s Research Hospital\
Memphis, Tennessee

Wendy Landier, RN, MSN, CPNP, CPON®\
Chair -- COG Nursing Clinical Practice Subcommittee\
Clinical Director - Survivorship Clinic\
City of Hope Comprehensive Cancer Center\
Duarte, California

Smita Bhatia, MD, MPH\
Chair -- COG Late Effects Committee\
Professor and Chair, Division of Population Sciences\
City of Hope Comprehensive Cancer Center\
Duarte, California

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

All Children\'s Oncology Group (COG) members have complied with the COG
conflict of interest policy, which requires disclosure of any potential
financial or other conflicting interests.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Children\'s Oncology Group.
Long-term follow-up guidelines for survivors of childhood, adolescent,
and young adult cancers. Version 1.2. 2004 Mar.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Children\'s Oncology Group Web
site](http://www.survivorshipguidelines.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Instructions for use. Long-term follow-up guidelines for survivors
    of childhood, adolescent, and young adult cancers. Version 2.0.
    Children\'s Oncology Group. 2006 March. 6 p.

-   Introductory material. Long-term follow-up guidelines for survivors
    of childhood, adolescent, and young adult cancers. Version 2.0.
    Children\'s Oncology Group. 2006 March. 9 p.

-   Summary of cancer treatment. Appendix I: Long-term follow-up
    guidelines for survivors of childhood, adolescent, and young adult
    cancers. Version 2.0. Children\'s Oncology Group. 2006 March.

-   Patient-specific guideline identification tool. Appendix I:
    Long-term follow-up guidelines for survivors of childhood,
    adolescent, and young adult cancers. Version 2.0. Children\'s
    Oncology Group. 2006 March.

Electronic copies: Available in Portable Document Format (PDF) from the
[Children\'s Oncology Group Web
site](http://www.survivorshipguidelines.org/).

#### PATIENT RESOURCES

In an effort led by the Nursing Clinical Practice Subcommittee,
complementary patient education materials (*Health Links*) were
developed and are available in Appendix II of the original guideline
document. The following Health Links are relevant to this summary:

**Sections 38, 39**

-   [Reducing the Risk of Second
    Cancer](http://www.survivorshipguidelines.org/pdf/ReducingSecondCancerRisk.pdf)

**Sections 39, 40**

-   [Skin
    Health](http://www.survivorshipguidelines.org/pdf/SkinHealth.pdf)

**Sections 43, 58**

-   [Educational
    Issues](http://www.survivorshipguidelines.org/pdf/EducationalIssues.pdf)

**Sections 48, 49, 71**

-   [Diet and Physical
    Activity](http://www.survivorshipguidelines.org/pdf/DietandPhysicalActivity.pdf)

**Section 50**

-   [Growth Hormone
    Deficiency](http://www.survivorshipguidelines.org/pdf/GrowthHormoneDeficiency.pdf)

**Section 51**

-   [Precocious
    Puberty](http://www.survivorshipguidelines.org/pdf/PrecociousPuberty.pdf)

**Section 52**

-   [Hyperprolactinemia](http://www.survivorshipguidelines.org/pdf/Hyperprolactinemia.pdf)

**Section 53, 62, 63, 64, 65**

-   [Thyroid
    Problems](http://www.survivorshipguidelines.org/pdf/ThyroidProblems.pdf)

**Sections 53, 54, 55**

-   [Hypopituitarism](http://www.survivorshipguidelines.org/pdf/Hypopituitarism.pdf)

**Section 50, 54, 86, 87**

-   [Male Health
    Issues](http://www.survivorshipguidelines.org/pdf/MaleHealthIssues.pdf)

**Sections 54, 83, 84**

-   [Female Health
    Issues](http://www.survivorshipguidelines.org/pdf/FemaleHealthIssues.pdf)

**Section 55**

-   [Central Adrenal
    Insufficiency](http://www.survivorshipguidelines.org/pdf/CentralAdrenalInsufficiency.pdf)

**Section 56**

-   [Cataracts](http://www.survivorshipguidelines.org/pdf/Cataracts.pdf)

**Section 57**

-   [Eye
    Health](http://www.survivorshipguidelines.org/pdf/EyeHealth.pdf)

**Section 58**

-   [Hearing
    Loss](http://www.survivorshipguidelines.org/pdf/HearingLoss.pdf)

**Sections 59, 60**

-   [Dental
    Health](http://www.survivorshipguidelines.org/pdf/DentalHealth.pdf)

**Section 61**

-   [Osteoradionecrosis](http://www.survivorshipguidelines.org/pdf/Osteoradionecrosis.pdf)

**Section 68**

-   [Breast
    Cancer](http://www.survivorshipguidelines.org/pdf/BreastCancer.pdf)

**Section 70**

-   [Pulmonary
    Health](http://www.survivorshipguidelines.org/pdf/PulmonaryHealth.pdf)

**Section 71**

-   [Heart
    Health](http://www.survivorshipguidelines.org/pdf/HeartHealth.pdf)

**Section 72**

-   [Splenic
    Precautions](http://www.survivorshipguidelines.org/pdf/SplenicPrecautions.pdf)

**Sections 73, 75, 76, 77**

-   [Gastrointestinal
    Health](http://www.survivorshipguidelines.org/pdf/GastrointestinalHealth.pdf)

**Section 74**

-   [Liver
    Health](http://www.survivorshipguidelines.org/pdf/LiverHealth.pdf)

**Section 78**

-   [Colorectal
    Cancer](http://www.survivorshipguidelines.org/pdf/ColorectalCancer.pdf)

**Section 79**

-   [Kidney
    Health](http://www.survivorshipguidelines.org/pdf/KidneyHealth.pdf)

-   [Single Kidney Health (mononephric patients
    only)](http://www.survivorshipguidelines.org/pdf/SingleKidneyHealth.pdf)

**Sections 80, 81, 82**

-   [Bladder
    Health](http://www.survivorshipguidelines.org/pdf/BladderHealth.pdf)

**Sections 89, 90**

-   [Scoliosis and
    Kyphosis](http://www.survivorshipguidelines.org/pdf/ScoliosisandKyphosis.pdf)

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI Institute on May 10, 2007. The
information was verified by the guideline developer on June 11, 2007.
This summary was updated by ECRI Institute on October 3, 2007 following
the U.S. Food and Drug Administration (FDA) advisory on Rocephin
(ceftriaxone sodium).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

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Date Modified: 11/3/2008