Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Appendix I

Materials forClinicalApplication

Version 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwide

Contents
Appendix I: Materials for Clinical Application of LTFU Guidelines

Page

Reference Materials

2

Abbreviations

3

Chemotherapy Agents

5

Radiation Fields Defined6

Radiation Dose Calculations

9

Guideline Radiation Sections by Field

10

Guideline Radiation Sections by Potential Impact

11

Total Body Irradiation (TBI) Related Potential Late Effects

14

Appeal Letter Following Denial of Insurance Claims for Survivorship Care

15

Instructions

16

Template for Letter from Patient, Parent, or Guardian17

Template for Letter from Long-Term Follow-Up Clinician

18

Summary of Cancer Treatment

19

Instructions

20

Template for Summary of Cancer Treatment (Abbreviated)

22

Template for Summary of Cancer Treatment (Comprehensive)

23

Key for Completing Summary of Cancer Treatment (Comprehensive)

25

Patient-Specific Guideline Identification Tool

31

Instructions

32

Patient-Specific Guideline Identification Tool (Version 6.0)

33

Section Number Comparison - COG LTFU Guidelines Version 6.0 vs 5.0

COG LTFU Guidelines Appendix I – Page 1

Table of Contents

39

Version 6.0 – October 2023

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Reference
Materials

Version 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwideAbbreviations
Abbreviation

Definition

Abbreviation

Definition

AAP

American Academy of Pediatrics

DOR

Diminished ovarian reserve

ABR

Auditory brainstem response

DTI

Diffusion-tensor imaging

ACIP

Advisory Committee on Immunization Practices

DWI

Diffusion-weighted imaging

ACS

American Cancer Society

DXA

Dual energy x-ray absorptiometry

AHA

American Heart Association

ECHO

Echocardiogram

ALL

Acute lymphoblastic leukemia

EKG

Electrocardiogram

ALT

Alanine aminotransferase

EIA

Enzyme immunoassay

AMH

Anti-Mullerian hormone

FAP

Familial adenomatous polyposis

AML

Acute myeloid leukemia

FM

Frequency modulated

AST

Aspartate aminotransferase

FNA

Fine needle aspirate

ATG

Anti-thymocyte globulin

FNH

Focal nodular hyperplasia

ATM

Ataxia telangiectasia cancer susceptibility gene(located on chromosome 11)

FSH

Follicle stimulating hormone

G-CSF

Granulocyte colony stimulating factor

AVN

Avascular necrosis

GH

Growth hormone

BMD

Bone mineral density

GI

Gastrointestinal

BMI

Body mass index

gm

Gram

BRCA1

Breast cancer susceptibility gene 1 (located on
chromosome 17)

GVHD

Graft versus host disease

Gy

Gray

Breast cancer susceptibility gene 2 (located on
chromosome 13)

HbA1c

Hemoglobin A1c

HBcAb

Hepatitis B core antibody

BUN

Blood urea nitrogen

HBsAg

Hepatitis B surface antigen

Ca

Calcium

HCT

Hematopoietic cell transplant

CAD

Coronary artery disease

HCV

Hepatitis C virus

CBC

Complete blood count

HDL

High-density lipoproteins

CCG

Children’s Cancer GroupHIB

Haemophilus influenzae type B

CDC

Centers for Disease Control

HIV

Human immunodeficiency virus

cGVHD

Chronic graft versus host disease

HLA

Human leukocyte antigen

Cl

Chloride

HNPCC

Hereditary nonpolyposis colorectal cancer

CNS

Central nervous system

HPF

High power field

CO2

Carbon dioxide

HPV

Human papillomavirus

COG

Children’s Oncology Groupht

HeightCRT

Cranial radiation

Hz

Hertz

CT

Computed tomography

IBD

Inflammatory bowel disease

CVRF

Cardiovascular risk factors

K

PotassiumdB

DecibelI-131

Iodine 131 radioisotope

DES

Diethylstilbestrol

IgA

Immunoglobulin A

DI

Diabetes Insipidus

IL-2Interleukin-2

DLCO

Diffusion capacity of carbon monoxide

IM

Intramuscular

BRCA2

COG LTFU Guidelines Appendix I – Page 3

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App I Contents

Abbreviations (cont)Abbreviation

Definition

Abbreviation

Definition

IMRTIntensity-modulated radiation therapy

PUVA

Psoralen plus ultraviolet-A radiation

IO

Intra-Ommaya

QTc

Corrected QT interval

IQIntelligence quotient

RB1

IT

Intrathecal

Retinoblastoma cancer susceptibility gene (locatedon chromosome 13)

IU

International unit

RBC

Red blood cellIV

Intravenous

RUQ

Right upper quadrant

IVIG

Intravenous immunoglobulin

SCUBA

Self-contained underwater breathing apparatus

kg

Kilogram

SDStandard deviation

KUB

Kidneys, ureters, bladder radiograph

SOS

Sinusoidal obstruction syndrome

LH

Luteinizing hormone

SQ

Subcutaneous

LV

Left ventricular

STLI

Subtotal lymphoid irradiationm

Square meter

T4

Thyroxine

MDS

Myelodysplastic syndrome

TBI

Total body irradiation

MIBG

Iodine-131-meta-iodobenzylguanidine

TLI

Total lymphoid irradiation

mg

Milligram

TPN

Total parenteral nutrition

Mg

Magnesium

TSH

Thyroid stimulating hormone

MMF

Mycophenolate mofetil

U

Units

MOPP

Mechlorethamine, Oncovin, Procarbazine,
Prednisone

USPSTF

United States Preventive Services Task Force

V-A

Ventriculoatrial

MR

Magnetic resonance

V-P

Ventriculoperitoneal

MRA

Magnetic resonance angiography

V-V

Ventriculovenus

MRI

Magnetic resonance imaging

VZIG

Varicella zoster immunoglobulin

Na

SodiumWAGR

NF1

Neurofibromin 1 (neurofibromatosis) cancer
susceptibility gene (located on chromosome 17)

Wilms' tumor, aniridia, genitourinary anomalies,
range of developmental delays

wt

Weight2

NHL

Non-Hodgkin lymphoma

NSAIDs

Non-steroidal anti-inflammatory drugs

p53

Cancer susceptibility gene associated with familial
cancers (located on chromosome 17)

PAP

Papanicolaou

PCR

Polymerase chain reaction

PFTs

Pulmonary function tests

PNET

Primitive neuroectodermal tumor

PNS

Peripheral nervous systemPOBy mouth

PO4

Phosphate

PSA

Prostate specific antigen

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Chemotherapy Agents
Generic Name

Additional Name(s)Classification

Asparaginase

EnzymeElsparErwinia asparaginase
Kidrolase®
L-asparaginase
Oncaspar®
PEG-asparaginase®

Generic Name

Additional Name(s)Classification

Ifosfamide

Ifex

Alkylating agent

Lomustine

CeeNU
CCNU

Alkylating agent

Mechlorethamine

Mustargen®
Nitrogen Mustard

Alkylating agent®
®

Bleomycin

Blenoxane®

Anti-tumor antibiotic

Melphalan

Alkeran®

Alkylating agent

BusulfanBusulfex
Busulphan
Myleran®

Alkylating agent

Mercaptopurine

6-Mercaptopurine
6MP
Purinethol®

Antimetabolite

Carboplatin

CBDCA
Paraplatin®

Heavy metal

Methotextrate

Antimetabolite

CarmustineBCNU
BiCNU®

Alkylating agent

Amethopterin
Folex®
Mexate®
Trexall®

Chlorambucil

Leukeran®

Alkylating agent

Mitoxantrone

Novantrone®

Anthracycline
antibiotic

Cisplatin

CDDP
Cisplatinum
Platinol®

Heavy metal

Prednisone

Corticosteroid

Cyclophosphamide

CPM
Cytoxan®
Neosar®
Procytox®

Alkylating agent

Deltasone®
Methylprednisolone
Prednisolone

Procarbazine

Matulane®
Natulan®

Alkylating agent

Temozolomide

Ara-C
Cytosar®
Cytosar-U®
Cytosine arabinoside

Antimetabolite

Temodal®
Temodar®

Non-classicalalkylator

Teniposide

VM26
Vumon®

Epipodophyllotoxin

Dacarbazine

DTIC
DTIC-Dome®

Non-classicalalkylator

Thioguanine

Antimetabolite

Dactinomycin

Actinomycin-D
Cosmegen®

Anti-tumor antibiotic

Lanvis®
Tabloid®
6-Thioguanine
6TG

Thiotepa

Thioplex®

Alkylating agent

Daunorubicin

Cerubidine
Daunomycin
DaunoXome®

Anthracycline
antibiotic

Vinblastine

VBL
Velban®
Velbe®

Plant alkaloid

Dexamethasone

Decadron®

Corticosteroid

Vincristine

Plant alkaloid

Doxorubicin

Adriamycin®
Doxil®
Rubex®

Anthracycline
antibiotic

Oncovin®
VCR
Vincasar®
Vincrex®

Epirubicin

Ellence®
Pharmorubicin PFS®

Anthracycline
antibiotic

Etoposide

VePesid®
VP16

Epipodophyllotoxin

Idarubicin

Idamycin®

Anthracycline
antibiotic

Cytarabine®

®

COG LTFU Guidelines Appendix I – Page 5

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Radiation Fields Defined
Traditional Radiation
Field

Definition

Corresponding
Version 5.0 Fields

Total body irradiation (TBI)

Entire body; encompassing all radiation fields

TBI

CranialAny field involving the cranium, head, brain and/or face

Head/brain

Waldeyer’s ring

Nasopharyngeal and oropharyngeal (tonsils and adenoids)

Head/brain

Spine-cervical

Including some or all of the cervical spine (C1–C7)

Spine (cervical)

Spine -thoracic

Including some or all of the thoracic spine (T1–T12)

Spine (thoracic)

Spine-lumbar

Including some or all of the lumbar spine (L1–L5)Spine (lumbar)

Spine-sacral

Including some or all of the sacral spine (S1–S5)Spine (sacral)

Spine-whole

Including the cervical, thoracic, lumbar and sacral spine

Spine (whole)Mini-mantle

Bilateral cervical (neck), supraclavicular and axillary fields (excludes mediastinal and lung) Neck
AxillaMantleBilateral cervical (neck), supraclavicular, mediastinal, hilar, and axillary fields

Neck
AxillaChest

Extended mantle

Mantle and paraaortic fields

Neck
AxillaChest
AbdomenSubtotal lymphoid
irradiation (STLI)

Mantle + paraaortic + splenic

Neck
AxillaChest
AbdomenInverted Y

Paraaortic + pelvic ± splenic

AbdomenPelvisTotal lymphoid irradiation(TLI)

Mantle + inverted Y (paraaortic/pelvic) + splenic

Neck
AxillaChest
AbdomenPelvisChest (thorax)

May include any of the following: Mediastinal, hilar, whole lung, chest wall

Chest

Mediastinal

Mediastinum and bilateral hilar fields

Chest

Abdomen(also commonly referred
to as “upper abdomen”)

Top of diaphragm to iliac crests (bilaterally), including the following fields:• Hepatic• Upper quadrant (right, left)• Renal/Renal bed• Paraaortic• Spleen (partial, entire)• Flank/Hemiabdomen (right, left)

AbdomenParaaortic

Paraaortic lymph nodes (generally from T10 to L4 cephalad-caudad, and the transverse
processes laterally) ± splenic

Abdomen

Renal

Renal bed

Abdomen

COG LTFU Guidelines Appendix I – Page 6

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Radiation Fields Defined (cont)Traditional Radiation
Field
Flank/Hemiabdomen

Definition

Corresponding
Version 5.0 Fields

Top of diaphragm to iliac crest (unilateral; medial border along contralateral vertebral
bodies)Abdomen± Pelvis

Note: Most hemiabdominal fields do not extend beyond the iliac crest; however, in somecases, depending on tumor location, the hemiabdominal field may have extended into
the pelvis. If the hemiabdominal field extended below the iliac crest, exposure to pelvic
fields should be considered in assessing risk for late sequelae.
Whole abdomen

Includes all abdominal and pelvic fields

AbdomenPelvisPelvisIliac crest to 3 cm below ischium, including the following fields:• Pelvic• Iliac• Vaginal• Inguinal• Prostate• Femoral• Bladder

PelvisExtremities

Including some or all of the arm(s), leg(s), feet or hand(s)Extremities

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Radiation Fields Defined (cont)Version 6.0 fields shown in black boxes

COG LTFU Guidelines Appendix I – Page 8

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Radiation Dose Calculations
Instructions for Radiation Dose Calculation:
Five sections of the COG Long-Term Follow-Up Guidelines (sections 60, 63, 66, 77, 78) include radiation dose specifications. These specifications
indicate the minimum dose of radiation that is believed (based on available evidence and the recommendations of the expert panel) to placepatients sufficiently at risk of the referenced late effect to recommend screening. For guideline sections that have a minimum specified dose, thefollowing considerations apply in determining the applicability of the section for a patient based on his/her radiation exposure.
Sections with minimum dose specifications are applicable to a patient only if:
1. Patient received radiation to any field(s) relevant to the particular guideline section at ≥ the specified minimum dose†OR
2. Patient received a combination of radiation to any relevant field(s)† plus relevant spinal radiation‡ and/or TBI, the sum of which is ≥ thespecified minimum dose
†Total dose to each field should include boost dose, if given. If patient received radiation to more than one field relevant to a particular guideline section during asingle planned course of radiation treatment (excluding spinal radiation and TBI), the field that received the largest radiation dose should be used in making
the determination as to the applicability of the indicated guideline section(s). Exception: If patient received radiation to the same field at different times (e.g., attime of diagnosis AND at relapse), these doses should be added together when considering the applicability of the indicated guideline section.
‡Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section.

Examples of Radiation Dose Calculations:
Step 1: If radiation was given to more than one field relevant to the guideline (not including spine, TBI), select the largest dose received
Step 2: If patient received radiation to the same field at different times (e.g., at time of diagnosis AND at relapse), add these doses together
Step 3: If patient received relevant spinal field radiation, add the largest relevant spinal dose
Step 4: If patient received TBI, add TBI dose
Example #1
Guideline Information

Patient Information

Guideline section

Minimum dose
specification
for screening

Relevant
Patient's relevant
radiation fields radiation fields

Step 1

Step 2

Section 66,
osteoradionecrosisof the jaw≥40 GyHead/Brain
Neck
Spine (cervical)
Spine (whole)
TBI

Radiation at diagnosis: 24 Gy• Head/Brain: 24 Gy• Neck: 18 Gy
Radiation at relapse:• Head/Brain: 12 Gy• TBI: 12 Gy

24 Gy

Step 3

Step 4N/A

36 Gy

Conclusion

48 Gy+ 12 Gy+ 12 Gy

36 Gy

48 Gy

Guideline
65 isapplicable

Example #2
Guideline Information

Patient Information

Guideline section

Minimum dose
specification
for screening

Relevant
Patient's relevant
radiation fields radiation fields

Section 77, cardiac
toxicity≥15 GyChest
AbdomenSpine (thoracic)
Spine (whole)
TBI

Radiation at diagnosis:• Chest: 6 Gy
Radiation at relapse:• Spine (whole):
12 Gy

Step 1

Step 2

Step 3

Step 4

Conclusion

6 Gy

N/A

6 Gy

N/A

18 Gy

+ 12 Gy
18 Gy

COG LTFU Guidelines Appendix I – Page 9

Guideline
76 isapplicable

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Guideline Radiation Sections by Field
Applicable guideline sections indicated in bold/dark blue; M=Male; F=Female*46, 47, 48, 49, 50, 51, 52,
53, 54M, 55F, 56, 57, 58M,
59F, 60*, 61, 62, 63*,
65, 66*, 67, 68, 69, 70, 71
64, 65, 66*, 67,
68, 69, 70, 71, 79
44, 45, 46,
47, 48, 53,
58M, 59F,
61, 64, 65,
67, 68, 69,
73F, 74F,
75, 76, 80,
81, 86, 87,
91M, 92F,
93F, 94F, 96

64, 65, 66*,
67, 68, 69, 70,
71, 72, 79

72, 77*, 79, 97
44,
45,
96,
97

72, 73F,
74F, 75, 76,
77*, 79, 97

Whole Spine64, 65, 66*, 67,
68, 69, 70, 71, 72,
77*, 79, 84, 85,
86, 88, 89, 92F,
93F, 94F, 97

84, 85, 86, 97

77*, 78*, 79,
80, 81, 82,
83, 84, 85,
86, 87, 97

84, 85, 86, 88, 89,
92F, 93F, , 94F

84, 85, 86, 88,
89, 92F, 93F,
94F, 95F

73F, 74F,
75, 76,

90M, 91M*Minimum dose
specifications apply.
For instructions andexamples regarding
radiation dose
calculations, refer to”Radiation Dose
Calculations” in COG
Long-Term Follow-Up
Guidelines Appendix I
Reference Materials.

COG LTFU Guidelines Appendix I – Page 10

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Guideline Radiation Sections by Potential Impact
Applicable guideline sections indicated in bold/dark blue; M=Male; F=Female

Potential Impact

Fields

Dose

SectionNumbers

Potential Late Effects

All Fields

Any radiation

Any

44*

Subsequent benign or malignant neoplasm

45*

Dermatologic toxicity

46*

Brain tumor (benign or malignant)47*

Neurocognitive deficits

48*

Clinical leukoencephalopathy

49

Cerebrovascular complications

50

Craniofacial abnormalities

51

Chronic sinusitis

52

Overweight; Obesity

53*

Growth hormone deficiency

54M

Precocious puberty (male)

55F

Precocious puberty (female)

56

Hyperprolactinemia

57

Central hypothyroidism

58M*

Gonadotropin deficiency (male)

59F*

Gonadotropin deficiency (female)≥30Gy**

60

Central adrenal insufficiency

Any

61*

Cataracts

62

Ocular toxicity

Brain/Cranium

Neuroendocrine
Axis

Eye

Head/Brain

Any

Head/Brain

Any

Head/Brain

Ear

Head/Brain≥30Gy**

63

Ototoxicity

Oral Cavity

Head/Brain
Neck
Spine (cervical, whole)

Any

64*

Xerostomia; Salivary gland dysfunction

65*

Dental abnormalities; Temporomandibular joint
dysfunction≥40 Gy**66

Osteoradionecrosis of the jaw

Any

67*

Thyroid nodules

68*

Thyroid cancer

69*

Hypothyroidism

70

Hyperthyroidism

71

Carotid artery disease72

Subclavian artery disease

Neck/Thyroid

Head/Brain
Neck
Spine (cervical, whole)

Neck
Chest
Spine (thoracic, whole)

Any* Patients who received TBI are at risk for this late effect. For a full list of TBI related sections, refer to "Total Body Irradiation Related Potential
Late Effects" in COG Long-Term Follow-Up Guidelines Appendix I Reference Materials.
**TBI should be included for dose calculation purposes only

COG LTFU Guidelines Appendix I – Page 11

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Guideline Radiation Sections by Potential Impact (cont)
Applicable guideline sections indicated in bold/dark blue; M=Male; F=Female

Potential Impact
BreastSectionNumbers
73F*

Potential Late Effects
Breast cancer

74F*

Breast tissue hypoplasia

75*

Pulmonary toxicity

76*

Lung cancer≥15 Gy**77

Cardiac toxicity

Abdomen≥40 Gy**78

Functional asplenia

Neck
Chest
AbdomenSpine (cervical, thoracic, whole)

Any

79

Esophageal stricture

AbdomenAny

80*

Impaired glucose metabolism/Diabetes mellitus

81*

Dyslipidemia

82

Hepatic toxicity

83

Cholelithiasis

84

Bowel obstruction

85

Chronic enterocolitis; Fistula; Strictures

86*

Colorectal cancer

Fields
Chest
Axilla

Dose
Any

Chest
Axilla

Any

Heart

Chest
AbdomenSpine (thoracic, whole)

SpleenGI/Hepatic
SystemLungs

AbdomenPelvisSpine (lumbar, sacral, whole)
Urinary Tract

Any

AbdomenAny

87

Renal toxicity

PelvisSpine (sacral, whole)

Any

88

Urinary tract toxicity

89

Bladder malignancy

Male
Reproductive
SystemTestesAny

90M

Testicular hormonal dysfunction

91M*

Impaired spermatogenesis

FemaleReproductive
SystemPelvisSpine (sacral, whole)

92F*

Ovarian hormone deficiencies

93F*

Diminished ovarian reserve (DOR)

94F*

Uterine vascular insufficiency

Musculoskeletal
SystemAny

PelvisAny

95F

Vaginal fibrosis/stenosis

Any radiation

Any

96*

Musculoskeletal growth problems

Chest
AbdomenSpine (thoracic, lumbar, whole)

Any

97

Scoliosis/Kyphosis

Any radiation

Any

98

Radiation-induced fracture* Patients who received TBI are at risk for this late effect. For a full list of TBI related sections, refer to "Total Body Irradiation Related Potential
Late Effects" in COG Long-Term Follow-Up Guidelines Appendix I Reference Materials.
**TBI should be included for dose calculation purposes only

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Guideline Radiation Sections by Potential Impact (cont)
Applicable guideline sections indicated in bold/dark blue; M=Male; F=Female

Brain/Cranium/Sensory
4646 4747 4848
4949 5050 5151
5252 5353 54M
54M
55F
55F5656 5757
58M
58M
59F
59F60*
60*
6161 6262 63*
63*

Oral Cavity
6464656566*
66*

Neck/Thyroid

676768686969
707071717272

4444
4545
4646
4747
4848
5353
58M
58M
59F
59F
6161
6464
6565
6767
6868
6969
73F
73F
74F
74F
7575
7676
8080
8181
8686
8787
91M
91M
92F
92F
93F
93F
94F
94F
9696

BreastEsophagus
7979

73F
73F74F
74F

Lungs

Heart

75757676

77*
77*

Liver/Pancreas
8080818182828383

4444
4545

Kidneys Spleen
8787

78*
78*

Bowel
8484
8585
Female Reproductive 8686
92F
92F93F
93F94F
94F95F
95F

Bladder/Urinary Tract
88888989

9696
9797
9898

Male
Reproductive*Minimum dose
specifications apply.
For instructions andexamples regarding
radiation dose
calculations, refer to”Radiation Dose
Calculations” in COG
Long-Term Follow-Up
Guidelines Appendix I
Reference Materials.

90M
90M91M
91M

Note: Oral cavity,
neck/thyroid, heart,esophagus, and bowel
are affected bymultiple anatomic
regions.

COG LTFU Guidelines Appendix I – Page 13

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Total Body Irradiation (TBI) Related Potential Late Effects
The complete list of potential late effects and associated Guideline section numbers are included here for clinician convenience when evaluating
patients who received TBI. For details regarding each potential late effect and indicated screening, please refer to the relevant section within the
Guidelines.
SectionNumberSex

Potential Late Effect

44

Both

Subsequent benign or malignant neoplasm occurring in or near radiation field

45

Both

Dermatologic toxicity

46

Both

Brain tumor (benign or malignant)

47

Both

Neurocognitive deficits

48

Both

Clinical leukoencephalopathy

53

Both

Growth hormone deficiency

58

Male

Gonadotropin deficiency

59

FemaleGonadotropin deficiency

61

Both

Cataracts

64

Both

Xerostomia; Salivary gland dysfunction

65

Both

Dental abnormalities; Temporomandibular joint dysfunction

67

Both

Thyroid nodules

68

Both

Thyroid cancer

69

Both

Hypothyroidism

73

FemaleBreast cancer

74

FemaleBreast tissue hypoplasia

75

Both

Pulmonary toxicity

76

Both

Lung cancer

80

Both

Impaired glucose metabolism/Diabetes mellitus

81

Both

Dyslipidemia

86

Both

Colorectal cancer

87

Both

Renal toxicity

91

Male

Impaired spermatogenesis

92

FemaleOvarian hormone deficiencies

93

FemaleDiminished ovarian reserve

94

FemaleUterine vascular insufficiency

96

Both

Musculoskeletal growth problems

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Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Appeal Letter
Following Denialof Insurance
ClaimsVersion 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwide

Instructions:Appeal Letter Following Denial of Insurance Claims for Survivorship Care
Not all insurance companies recognize the need for ongoing long-term follow-up care for survivors of childhood, adolescent, and young adultcancers. As with any medical care, it is prudent for the survivor to determine coverage for anticipated screening tests that may be recommended
as part of their long-term follow-up care, and to work with the survivorship provider to obtain any pre-authorizations that may be necessary.
Nevertheless, we recognize that some essential services may be denied from time to time. The letters on the following pages are designed foruse as templates to appeal denial letters from insurance companies, should the need arise. One letter is designed to be completed and submitted
to the insurance company by the patient (or his/her parent). The other letter is designed to be completed and submitted to the insurance company
by the patient’s survivorship care provider. Although neither letter can guarantee insurance coverage, we are hopeful that these letters may be
helpful in securing the indicated coverage for tests recommended as part of routine long-term follow-up care after the completion of cancerdirected therapy.
These templates were developed by Kristy Sharif and Alison Olig, COG Patient Advocacy Committee, 2018.

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Appeal Letter Following Denial of Insurance Claims for Survivorship Care:
Template for Letter from Patient, Parent or Guardian(Date)(Name)(Insurance Company Name)(Address)(City, State ZIP)Re:

(Patient's Name)(Type of Coverage)(Group number/Policy number)

Dear (name of contact person at insurance company),
Please accept this letter as (patient's name)’s appeal to (insurance company name)’s decision to deny coverage for (name of test). It is myunderstanding based on your letter of denial dated (date) that (name of test) has been denied because:(Quote the specific reason for the denial stated in denial letter)
It is possible that you did not have all the necessary information at the time of your initial review. (Patient's name) was diagnosed with (disease)on (date). Currently (name of long-term follow-up clinician) from (name of treating facility), a specialist in long-term follow-up after therapy
for cancer during childhood, adolescence, and young adulthood, has indicated that (patient's name) requires (name of test) in order to monitor
for long-term complications related to (patient’s name) cancer treatment. Please see the enclosed letter from (name of long-term follow-up
clinician) that discusses (patient's name)’s medical history and provides justification for this testing in more detail. Also included are medical
records and support documentation explaining the evidence-based recommendations for this required monitoring.
Based on this information, (patient's name) is asking that you reconsider your previous decision and allow coverage for the procedure Dr. (name)outlines in the enclosed letter. (Name of test) is recommended to be completed by (date). Should you require additional information, please do
not hesitate to contact me at (phone number). I look forward to hearing from you in the near future.
Sincerely,(Patient, parent or guardian name)

COG LTFU Guidelines Appendix I – Page 17

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App I Contents

Appeal Letter Following Denial of Insurance Claims for Survivorship Care:
Template for Letter from Long-Term Follow-Up Clinician(Date)(Name)(Insurance Company Name)(Address)(City, State ZIP)Re:

(Patient's Name)(Type of Coverage)(Group number/Policy number)

Dear (name of contact person at insurance company),
This letter is written in support of (patient's name)’s appeal to (insurance company name)’s decision to deny coverage for (name of test).
I am the clinician who is currently providing long-term follow-up care for this patient. Based on your letter of denial dated (date), it is myunderstanding that (name of test) has been denied because:(Quote the specific reason for the denial stated in denial letter)(Patient's name) is a (age) year old (male/female) who was diagnosed with (disease) on (date) and began treatment on (date). Treatment wascompleted on (date).
The treatments that (patient's name) received for (disease) were lifesaving, however, this treatment has the potential to cause significant
long-term complications (late effects) that can negatively impact (patient’s name)’s health. Ongoing monitoring is required so that any long-term
complications of cancer therapy can be identified and treated in a timely fashion in order to optimize (patient’s name)’s health and prevent a
decline in health status.
Because (patient's name) received (name of relevant therapeutic exposures/doses) as part of (his/her) cancer therapy, (he/she) is at risk for(relevant late effect(s)). The Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines, which set the standard of care for the ongoing
follow-up of survivors of childhood, adolescent, and young adult cancers, provide specific follow-up recommendations related to (patient’sname)’s treatment, including (name of test denied). These evidence-based guidelines are based on the known long-term risks associatedwith cancer therapy delivered during childhood, adolescence, and young adulthood. The recommendations within the COG Long-Term Follow-Up
Guidelines represent the consensus of experts in the late effects of pediatric cancer treatment.
I have attached documentation that supports the recommended testing in more detail [attach relevant sections from COG LTFU Guidelines andany additional supportive materials such as journal articles], along with (patient’s name)’s relevant medical records. Additional information
is available from the Children’s Oncology Group at www.survivorshipguidelines.org.
Based on this information, as the clinician providing (patient's name)’s long-term follow-up care, I am asking that you reconsider your previous
decision and allow coverage for (name of test). (Name of test) is recommended to be completed by (date). Should you require additional
information, please do not hesitate to contact me at (phone number). I look forward to hearing from you
Sincerely,(Name of long-term follow-up clinician)

COG LTFU Guidelines Appendix I – Page 18

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App I Contents

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Summaryof Cancer
Treatment

Version 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwide

Instructions:
Summary of Cancer Treatment
Importance of a Comprehensive Cancer Treatment Summary
The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are based ontherapeutic exposures received during cancer treatment. Availability of a comprehensive treatment summary, including all therapeutic agentsreceived by the survivor, is presumed. Patients who do not have a comprehensive treatment summary should be instructed to obtain one from theinstitution(s) where they received their treatment.
The following table outlines:
1. The minimum information necessary to generate patient-specific guidelines (i.e., an abbreviated treatment summary).
2. The ideal information included in the comprehensive treatment summary. We strongly advise that a comprehensive treatment summary
be prepared for each childhood cancer survivor when feasible.

At Minimum

Additional Information- Strongly Advised if Feasible

Demographics

Demographics• Name• Sex• Date of birth• Race/Ethnicity• Social security number, if available• COG registration number, if available• Contact information

Cancer Diagnosis

Cancer Diagnosis• Diagnosis• Date of diagnosis• Date cancer therapy was completed• Diagnosis, including date, site/stage, laterality, and relapse(s) if any• Pertinent hereditary conditions, past medical history and subsequent
neoplasms• Treating institution and teamCancer Treatment: Protocols

Cancer Treatment: Protocols

N/A• Treatment protocol information, if applicable

Cancer Treatment: Chemotherapy

Cancer Treatment: Chemotherapy• Names of all chemotherapy agents received– For a list of chemotherapy agents addressed by these guidelines(Sections 11-43), see the “Chemotherapy” portion of the Patient-Specific
Guideline Identification Tool in Appendix I.
– For generic and brand names of chemotherapy agents, see
Chemotherapy Agents in Appendix I.
• Cumulative dose of all anthracycline chemotherapy received (i.e.,
doxorubicin, daunorubicin, idarubicin, mitoxantrone and epirubicin)– See Section 34 of Guidelines for anthracycline isotoxic dose-equivalent
conversion.
– For doses in mg/kg, multiply by 30 to obtain equivalent dosing in mg/m2(example: 2 mg/kg = 60 mg/m2).
• For carboplatin, whether any dose was myeloablative (i.e., given as
conditioning for HCT)• For cytarabine and methotrexate:– Route of administration (i.e., IV, IM, SQ, PO, IT, IO)– If IV, designation of “high dose” (any single dose ≥ 1000 mg/m2) versus“standard dose” (all single doses < 1000 mg/m2)• Cumulative doses for all other agents should be provided if available,
particularly for alkylators and bleomycin.
– For doses in mg/kg, multiply by 30 to obtain equivalent dosing in mg/m2(example: 2 mg/kg = 60 mg/m2).
• Route of administration for all other agents

COG LTFU Guidelines Appendix I – Page 20

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App I Contents

Instructions:
Summary of Cancer Treatment (cont)At Minimum

Additional Information- Strongly Advised if Feasible

Cancer Treatment: Radiation

Cancer Treatment: Radiation• Laterality (if applicable), start/stop dates, radiation type, number of• Names of all radiation field(s) treatedfractions, dose per fraction, boost dose/location (if applicable)– For list of radiation fields addressed by these guidelines (Sections 44-98),• Total dose (in Gy) for all other fields
see “Radiation” portion of the Patient-Specific Guideline Identification
Tool in Appendix I– Should include boost dose if given– For definition of radiation fields, see "Radiation Fields Defined" in– To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy =Appendix I
2400 rads = 24 Gy)• For head/brain, neck, chest, abdomen, spine (whole, cervical, thoracic)• Treating institution and radiation oncologist
radiation and TBI, total dose (in Gy):
– Total radiation dose to each field (should include boost dose, if given)– To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy =2400 rads = 24 Gy)
Cancer Treatment: Hematopoietic Cell Transplant(s)Cancer Treatment: Hematopoietic Cell Transplant(s)• Whether or not the survivor underwent a hematopoietic cell transplant(HCT), and if so:– Transplant type (autologous vs allogeneic)– Chronic graft-versus-host disease (cGVHD) status (no history of chronic
GVHD, history of chronic GVHD, currently active chronic GVHD)• Type(s), source(s), date(s), conditioning regimen(s), GVHD prophylaxis and/or treatment• Treating institution and transplant physician

Cancer Treatment: Surgery

Cancer Treatment: Surgery• Names of all surgical procedures.
– For list of surgical procedures addressed by these guidelines (Sections
115–151), see “Surgery” portion of the Patient-Specific Guideline
Identification Tool in Appendix I• Dates, site (if applicable), laterality (if applicable)• Treating institution and surgeon

Cancer Treatment: Other Therapeutic Modalities

Cancer Treatment: Other Therapeutic Modalities• Whether or not the survivor received radioiodine therapy (I-131 thyroid
ablation), systemic MIBG (in therapeutic doses), or a novel therapy• Names, routes and cumulative doses of all other therapeutic modalities
received

Additional Clinical Information

Additional Clinical Information

N/A• Significant complications/late effects with dates of onset/resolution• Adverse drug reactions/allergies• Additional information/comments

Templates for Summary of Cancer Treatment
Two templates for summarizing cancer treatment are included in Appendix I (also available in electronic format atwww.survivorshipguidelines.org). These templates were originally developed by the COG Nursing Clinical Practice Subcommittee under theleadership of Lisa Bashore, MS, RN, CPNP, CPON® and Lori Boucher, RN, CRA. The templates were subsequently pilot tested and revised, thenfurther refined based on feedback from the Late Effects Committee and a working group from the National Cancer Institute.
The abbreviated form contains all data elements currently necessary for generation of patient-specific recommendations from the COG LTFU
Guidelines, and meets the minimum data requirements for initial use of the “Passport for Care” web-based guideline interface. However, theCOG Long-Term Follow-Up Guidelines Core Committee recognizes that as new evidence becomes available and these guidelines are updated,additional details regarding the childhood cancer survivor’s therapeutic exposures may be required in order to generate comprehensive
recommendations. Therefore, we strongly advise that a comprehensive treatment summary be prepared for each childhood cancer survivor
when feasible, including a record of all therapeutic exposures with applicable dates, details of administration, and cumulative doses of all agents,
including those not currently addressed by these guidelines.
In addition to the treatment summary templates, a “key” for completing the comprehensive version of the treatment summary is also included inAppendix I.

COG LTFU Guidelines Appendix I – Page 21

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App I Contents

Summary of Cancer Treatment (Abbreviated)
Demographics
Name

Sex  M  F

Date of birth

Cancer Diagnosis
Diagnosis

Date of diagnosis

Chemotherapy

 Yes

 No

Date therapy completed

If yes, provide information below

Drug name

Additional information††
Anthracyclines: Include cumulative dose in mg/m2 (see section 34 of Guidelines for isotoxic dose conversion);
Carboplatin: Indicate if dose was myeloablative
Methotrexate and Cytarabine: Indicate route of administration (i.e., IV, IM, SQ, PO, IT, IO);IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose ≥ 1000 mg/m2) or “standard dose” (all single doses < 1000 mg/m2)
Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

Radiation

 Yes

 No

If yes, provide information below

Site/Field

Total dose* (including boost) (Gy)***For head/brain, neck, chest, abdomen, spine (whole, cervical, thoracic) radiation and TBI, include total doses (including boost dose, if given)**To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)

Hematopoietic Cell Transplant

 Yes

 No

If yes, provide information below

Transplant type

Autologous  Yes

Chronic graft-versus-host disease (cGVHD)

Ever diagnosed?  Yes

Surgery

 Yes

 No

Allogeneic  Yes

 No

 No

Currently active?  Yes

 No

If yes, provide information below

Procedure

Other Therapeutic Modalities

 No

Site (if applicable)

 Yes

 No

Laterality (if applicable)

If yes, provide information below

Did the patient receive radioiodine therapy (I-131 thyroid ablation)?
Did the patient receive systemic MIBG (in therapeutic doses)?

 Yes

 Yes

 No

 No

Did the patient receive any other novel therapy from Sections 158-163 (in therapeutic doses)?
Summary prepared by:

 Yes

 No
Date prepared:

COG LTFU Guidelines Appendix I – Page 22

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App I Contents

Summary of Cancer Treatment (Comprehensive)
Superscript numbers correspond with lists in "Key for Completing Summary of Cancer Treatment Form"
Demographics
Name
Date of birth

Sex  M  F

Race/Ethnicity1

SS#

COG Reg #Address

Phone

Alternate contact

Relationship

Phone

Cancer Diagnosis
Diagnosis2
Date of diagnosis

Age at diagnosis

Date therapy completed

Sites involved/Stage/Diagnostic details
Hereditary/Congenital history

Laterality  Right  Left  NA

3

Pertinent past medical history
Institution

MD/APN

Relapse(s)

 Yes

 No

Medical record #If yes, provide information below

Date of diagnosis

Age at diagnosis

Date therapy completed

Sites involved/Stage/Diagnostic details
Subsequent malignant neoplasm(s)Laterality  Right  Left  NA
 Yes

 No

If yes, provide information below

Type4
Date of diagnosis

Age at diagnosis

Date therapy completed

Sites involved/Stage/Diagnostic details

Laterality  Right  Left  NA

Cancer Treatment Summary
Protocol(s) YesAcronym/Number

Chemotherapy

 No

If yes, provide information below

Title/Description

 Yes

 No

Initiated

CompletedOn-study

If yes, provide information below

Drug name5

Route6

Additional information†,7

Anthracyclines: Include cumulative dose in mg/m2 and age at first dose (see section 34 of Guidelines for isotoxic dose conversion);
Carboplatin: Indicate if dose was myeloablative
IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose ≥ 1000 mg/m2) or “standard dose” (all single doses < 1000 mg/m2);
Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

†

COG LTFU Guidelines Appendix I – Page 23

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Summary of Cancer Treatment (Comprehensive) (cont)
Cancer Treatment Summary (cont)
Radiation Yes

Site/Field8

Laterality

 No

If yes, provide information below
Start/Stop
dates

Type9

Fractions

Institution

Dose perfraction(Gy)*

Initialdose (Gy)*

Boost site10

Boost
dose (Gy)*

Total dose(including
boost) (Gy)*Radiation oncologist*Note: To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)
Hematopoietic Cell Transplant

 Yes

 No

If yes, provide information below

Tandem?

Type11 Yes

Source12

Date of infusion

 No

Institution

Transplant physician

Graft-Versus-Host Disease (GVHD) Prophylaxis/Treatment (for transplant patients only)

Was the patient ever diagnosed with chronic GVHD?
 Yes

 No

Procedure15

 Yes

 No

 No

If yes, provide information below

Last dose

Does the patient currently have active chronic GVHD?

 Yes

 No

If yes, provide information below
Date

Other Therapeutic Modalities
Therapy YesFirst dose

Type

14

Surgery

Conditioning regimen13

Site (if applicable)

 Yes

 No

Laterality (if applicable)

Institution/Surgeon

If yes, provide information below
Route6

16

Cumulative dose7 (if known)

Additional Clinical Information
Complications/Late Effects

 Yes

Problem17

 No

If yes, provide information below

Date onset

Adverse Drug Reactions/Allergies

 Yes

Drug

Reaction

Date resolved

 No

Status Active Resolved

 Active Resolved

 Active Resolved

 Active Resolved

If yes, provide information below
Date

Status Active

Additional Information/Comments

 Yes

 No

 Resolved

If yes, provide information below

Summary prepared by:Date prepared:

Summary updated by:Date updated:

COG LTFU Guidelines Appendix I – Page 24

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App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)#1: Race/Ethnicity#2: Cancer Diagnosis (cont)#2: Cancer Diagnosis (cont)

Asian

Germ cell tumor (extracranial) (cont)

Sarcoma (cont)Black/African American

Germ cell tumor, other, specify:

Caucasian (non-Hispanic/non-Latino)Langerhans cell histiocytosis

Soft tissue sarcoma (nonrhabdomyosarcomatous)(cont)

Hispanic or Latino

Leukemia

Native American/Alaskan Native

Acute lymphoblastic leukemia

Native Hawaiian/Pacific Islander

Acute myeloid leukemia

Multi-racial/multi-ethnic

Chronic myeloid leukemia

Race/ethnicity, other, specify:

Myelodysplastic syndrome#2: Cancer Diagnosis

Myeloproliferative disorder

Central Nervous System Tumor

Leukemia, other, specify:

Astrocytoma

Liver tumor

Cerebellar astrocytoma

Hepatoblastoma

Supratentorial astrocytoma

Hepatocellular carcinoma

Synovial sarcoma
Undifferentiated sarcoma
Sarcoma, other, specify:
Skin cancer
Basal cell carcinoma
Malignant melanoma
Squamous cell carcinoma
Skin cancer, other, specify:
Malignancy, other, specify:
Diagnosis, other, specify:#3: Hereditary/Congenital History

Brainstem glioma

Liver tumor, other, specify:

Choroid plexus neoplasm

Lymphoma

Craniopharyngioma

Hodgkin lymphoma

Ependymoma

Non-Hodgkin lymphoma

Germ cell tumor, intracranial

Lymphoblastic lymphoma

Neurofibromatosis
Specify:  Type I  Type II

Optic glioma

Burkitt’s lymphoma

Down syndrome

Pineal tumor

Large cell lymphoma

Syndrome, other, specify:

PNET
Cerebellar (medulloblastoma)
Supratentorial PNET

Congenital heart disease
Congenital disease, other, specify:
Hemihypertrophy

Anaplastic large cell lymphoma

Hereditary condition, other, specify:

Diffuse large B-cell lymphoma

None

Lymphoma, other, specify:

Unknown

Spinal cord tumor, intramedullary

Nasopharyngeal carcinoma#4: Subsequent Malignancy Diagnosis

CNS tumor, other, specify:

Neuroblastoma

Bladder cancer

Endocrine tumor

Ganglioneuroblastoma

Breast cancer

Adrenal tumor (non-neuroblastoma)

Renal tumor

Central nervous system tumor

Thyroid tumor

Wilms tumor

Malignant, specify type and location:

Parathyroid tumor

Clear cell sarcoma

Meningioma, specify location:

Gastroenteropancreatic tumor

Renal cell carcinoma

CNS tumor, other, specify type:Multiple endocrine neoplasia syndrome

Renal tumor, other, specify:

Cervical cancer

Endocrine tumor, other, specify:

Retinoblastoma

Gastrointestinal cancer

Germ cell tumor (extracranial)

Sarcoma

Esophageal cancer

Seminoma

Ewing’s sarcoma/peripheral PNET

Stomach cancer

Germinoma

Osteogenic sarcoma

Colorectal cancer

Dysgerminoma

Rhabdomyosarcoma

Hepatocellular carcinoma

Soft tissue sarcoma (nonrhabdomyosarcomatous)

Pancreatic cancer

Non-seminomas
Yolk sac tumor

Alveolar soft part sarcoma

GI cancer, other, specify:

Embryonal carcinoma

Fibrosarcoma

Leukemia

Choriocarcinoma

Leiomyosarcoma

Acute lymphoblastic leukemia

Liposarcoma

Acute myeloid leukemia

MatureMalignant fibrous histiocytoma

Chronic myeloid leukemia

Immature

Malignant peripheral nerve sheath tumor

Myelodysplastic syndrome

With malignant transformation

Neurofibrosarcoma

Myeloproliferative disorder

Teratoma

COG LTFU Guidelines Appendix I – Page 25

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App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)(cont)#4 Subsequent Malignancy Diagnosis (cont)#5: Chemotherapy (cont)#6: Route

Leukemia (cont)

Cyclophosphamide

PO

Leukemia, other, specify:

Cytarabine
If IV: any single dose ≥ 1000 mg/m2?  Yes  No

IMLung cancer
Lymphoma

Dacarbazine (DTIC)

SQ

Hodgkin lymphoma

Dactinomycin

IT

Non-Hodgkin lymphoma

Daunorubicin

IO

Lymphoblastic lymphoma

Dexamethasone

Route, other, specify:

Burkitt lymphoma

Docetaxel

Unknown

Large cell lymphoma

DoxorubicinIV#7: Cumulative Dose
(Note: this is a required field for anthracyclines andoptional but suggested for all others )Post-transplant lymphoproliferative disorder (PTLD)

Epirubicin

Lymphoma, other, specify:

Etoposide (VP-16)

Peripheral nerve sheath tumor/
Schwannoma/Acoustic neuroma

Fludarabine

Renal cancer

Gemcitabine

Renal cell carcinoma

Hydrocortisone

Clear cell sarcoma

Hydroxyurea

mg/kg(Note: computer will multiply mg by 30 and display
as mg/m2 )Renal cancer, other, specify:

Idarubicin

Not available

Sarcoma

Ifosfamide

Not applicable

Ewing’s sarcoma/peripheral PNET

Imatinib Mesylate

Cumulative dose, other, specify:

Osteogenic sarcoma

Irinotecan

Unknown

Rhabdomyosarcoma

Lomustine (CCNU)#8: Radiation Site/Field

Soft tissue sarcoma (nonrhabdomyosarcomatous)

Mechlorethamine

Head/brain

Undifferentiated sarcoma

Melphalan

CranialSarcoma, other, specify:

Mercaptopurine

Skin cancer
Basal cell carcinoma

Methotrexate
If IV: Any single dose ≥ 1000 mg/m2?  Yes  No

Orbital/EyeSpecify:  Right  Left  Bilateral

Malignant melanoma

Mitoxantrone

Ear/Infratemporal
Specify:  Right  Left  BilateralSquamous cell carcinoma

Oxaliplatin

Nasopharyngeal

Thyroid cancer

Paclitaxel

Oropharyngeal

Malignancy, other, specify:

Prednisone

Waldeyer’s ring

None

Procarbazine

Head/brain radiation, other, specify:

Unknown

Temozolomide

Neck#5: Chemotherapy

Teniposide (VM-26)

Asparaginase

Thioguanine (6-TG)

Cervical (neck)Specify:  Right  Left  Bilateral

Bleomycin

Thiotepa

SupraclavicularSpecify:  Right  Left  Bilateral

BusulfanTopotecan

Spine

Carboplatin
Myeloablative dose?  Yes  No

Trimetrexate

Spine – cervical

Vinorelbine

Spine – thoracic

Carmustine (BCNU)

Vinblastine

Spine – lumbar

Chlorambucil

Vincristine

Spine – sacral

Cisplatin

Chemotherapy, other, specify:

Spine – whole

Cladribine

None

Clofarabine

Unknown

AxillaSpecify:  Right  Left  Bilateral

mg/m2

Fluorouracil

units/m2

COG LTFU Guidelines Appendix I – Page 26

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App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)(cont)#8: Radiation Site/Field (cont)#8: Radiation Site/Field (cont)

Chest

Radiation site/field, other, specify:#13: Hematopoietic Cell Transplant (HCT) –Conditioning Regimen (cont)Chest (thorax)

None

Melphalan

Whole lungSpecify:  Right  Left  Bilateral

Unknown

Thiotepa

Add comment:

Total body irradiation (TBI)Mediastinal#9: Radiation TypeHCT conditioning regimen, other, specify:

Chest, other, specify:

Brachytherapy

Unknown

Abdomen

Conformal

Hepatic

External beam (conventional)#14: Graft versus host disease (GVHD)
Prophylaxis/Treatment

Renal
Specify:  Right  Left  Bilateral

Intensity-modulated radiation therapy (IMRT)

Upper quadrant
Specify:  Right  Left  Bilateral

Stereotactic

SpleenSpecify:  Partial  Entire

Proton beam

Cyclosporine
Methotrexate
Myophenolate mofetil (MMF)

Radiation type, other, specify:

Prednisone

None

Psoralen plus ultraviolet-A radiation (PUVA)

Paraaortic

Unknown

Flank/hemiabdomenSpecify:  Right  Left
Specify: Extended below iliac crest:  Yes  No

#10: Radiation Boost

Pelvis

None

PelvicUnknown

Vaginal

Add comment:

Prostate#11: Hematopoietic Cell Transplant (HCT) – Type

Bladder

Autologous

Iliac

Matched related

Inguinal

Mismatched relatedFemoralHaploidentical related

TesticularSpecify:  Right  Left  Bilateral

Syngeneic

Extremity

HCT type, other, specify:

Upper
Specify:  Right  Left  BilateralSpecify:  Proximal  Distal  Entire

Unknown

Lower
Specify:  Right  Left  BilateralSpecify:  Proximal  Distal  Entire

Peripheral blood stem cells

Total Body Irradiation (TBI)

HCT source, other, specify:

Sirolimus
Tacrolimus

Tumor bed, specify location:
Radiation boost location, other, specify:

GVHD prophylaxis/treatment, other, specify:
None
Unknown#15: Surgery
Amputation, specify site:
Specify:  Right  Left  BilateralCentral venous catheter
Cystectomy
Enucleation
Specify:  Right  Left  Bilateral
Hysterectomy

Matched unrelated

Laparotomy
Limb sparing procedure, specify site:
Specify:  Right  Left  Bilateral#12: Hematopoietic Cell Transplant – Source
Bone marrow

Nephrectomy
Specify:  Right  Left  Bilateral
Neurosurgery – brain
Potential to affect hypothalamic-pituitary axis?
 Yes  No

Cord blood

Neurosurgery – spinal cord

Combination Fields:

Unknown

Mantle#13: Hematopoietic Cell Transplant –Conditioning Regimen

Mini-mantle

Anti-thymocyte globulin (ATG)

Oophoropexy
Oophorectomy
Specify:  Right  Left  Bilateral

Extended mantle

Anti-thymocyte globulin (ATG)

Inverted Y

Busulfan

Whole abdomen

Carmustine (BCNU)

Orchiectomy
Specify:  Partial  Unilateral  BilateralIf partial or unilateral, specify:  Right  Left

Total lymphoid irradiation (TLI)

Cyclophosphamide

Pelvic surgery

Subtotal lymphoid irradiation (STLI)

Etoposide

Thoracic surgery*

Fludarabine

Splenectomy

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App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)(cont)#15: Surgery (cont)Thyroidectomy#17: Complications/Late Effects (by system)(cont)#17: Complications/Late Effects (by system)(cont)

Surgery, other, specify:

Cardiovascular (cont)Central Nervous System (CNS) (cont)

None

Atherosclerotic heart diseaseOcclusive cerebral vasculopathy

Unknown

Cardiomyopathy

Paralysis

Add comment:

Carotid artery disease

Seizures*Thoracic surgery includes: thoracotomy, chestwall surgery, rib resection, pulmonary lobectomy,
pulmonary metastasectomy, and pulmonary
wedge resection

Congestive heart failure

Shunt malfunction

Infection of retained cuff or line tract

Spasticity

Myocardial infarction

StrokePericardial fibrosis

CNS complication, other, specify:

Pericarditis

DentalPost-thrombotic syndrome

Dental caries

Subclavian artery disease

Ectopic molar eruption

Subclinical left ventricular dysfunction

Enamel dysplasia

Systemic radiation, other, specify:

Thrombosis

Malocclusion

Bioimmunotherapy

Valvular disease

Microdontia

Hematopoietic growth factors:

Vascular insufficiency

Osteoradionecrosis of the jaw

Granulocyte colony stimulating factor (G-CSF)

Cardiovascular complication, other, specify:

Periodontal disease

Erythropoietin

Central Nervous System (CNS)

Root thinning/shortening

Thrombopoietin

AtaxiaSalivary gland dysfunction

Cavernomas

Temporomandibular joint dysfunction

Alpha interferon

Chronic pain, central neuropathic

Tooth/root agenesis

Gamma interferon

Clinical leukoencephalopathy

Xerostomia

Dysarthria

Dental complication, other, specify:

IL-2

Dysphagia

Dermatologic

IL-11

Hemiparesis

Altered skin pigmentation

Other, specify:

Hydrocephalus

Nail dystrophy

Monoclonal antibody, specify type:

Movement disorders

Permanent alopecia

Retinoic acid, specify type:

Moyamoya

Sclerodermatous changes

Bioimmunotherapy, other, specify:

Neurocognitive deficits

Skin fibrosis

Other therapeutic modality, specify:

Academic fluency

Telangiectasias

None

Behavioral change

Vitiligo

Unknown

Diminished IQ

Dermatologic complication, other, specify:#17: Complications/Late Effects (by system)

Executive function (planning and organization)

Endocrine/Metabolic

Auditory

Fine motor dexterity

Central adrenal insufficiency

Conductive hearing loss

Language

Diabetes insipidus

Eustachian tube dysfunction

Learning deficits in math and reading(particularly reading comprehension)

Dyslipidemia

Sensorineural hearing loss

Memory (particularly visual, sequencing,temporal memory)

Growth hormone (GH) deficiency

Tinnitus

Processing speed

Tympanosclerosis

Sustained attention

VertigoVisual-motor integration#16: Other Therapeutic Modalities
Systemic Radiation
Radioiodine therapy (I-131 thyroid ablation)
Systemic Iodine metaiodobenzylguanidine (MIBG)(in therapeutic doses)

Interferon:Interleukin (IL):

Otosclerosis

Auditory complication, other, specify:

Neurogenic bladder

Cardiovascular

Neurogenic bowel

Gonadotropin deficiency (LH/FSH deficiency)
Hyperprolactinemia
Hyperthyroidism
Hypothyroidism, primary(thyroid gland failure)
Hypothyroidism, central/secondary(T4/TSH deficiency)

Arrhythmia

COG LTFU Guidelines Appendix I – Page 28

Version 6.0 – October 2023
Table of Contents

App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)(cont)#17: Complications/Late Effects (by system)(cont)#17: Complications/Late Effects (by system)(cont)#17: Complications/Late Effects (by system)(cont)

Endocrine/Metabolic (cont)

Immune (cont)Ocular (cont)Impaired glucose metabolism/diabetes mellitus

Immune complication, other, specify:

Xerophthalmia (keratoconjunctivitis sicca)

Overweight [Body Mass Index (BMI)]
Age 2–20 yrs: BMI for age ≥ 85 – <95%ile
Age > 20 yrs: BMI 25 to 29.9

Musculoskeletal

Ocular complication, other, specify:

Chronic pain, musculoskeletal

Peripheral Nervous System (PNS)

Contractures

Areflexia

Fibrosis

Chronic pain, peripheral neuropathic

Functional and activity limitations

Dysesthesias

Precocious puberty

Hypoplasia

Foot drop

Thyroid nodule

Impaired cosmesis

Paresthesias

Endocrine/metabolic complication, other, specify:

Increased energy expenditure (related to
amputation/limb salvage)

Vasospastic attacks (Raynaud's phenomenon)

Kyphosis

PNS complication, other, specify:

Limb length discrepancy

Psychosocial

Osteonecrosis (avascular necrosis)

Anxiety
Dependent living

Cirrhosis

Prosthetic malfunction(loosening, non-union, fracture) requiring revision,
replacement or amputation

Esophageal stricture

Radiation-induced fracture

Educational problems

Fecal incontinence

Reduced bone mineral density (BMD)

Fatigue

FistulaReduced or uneven growth

Limitations in healthcare and insurance access

Focal nodular hyperplasia

Residual limb integrity problems

Impaired quality of life

Hepatic dysfunction

Scoliosis

Post-traumatic stress

Hepatic fibrosis

Shortened trunk height

Psychological maladjustment

Iron overload

Musculoskeletal complication, other, specify:

Psychosocial disability due to pain

Sinusoidal obstruction syndrome (SOS) [previously
known as veno-occlusive disease (VOD)]

OcularRelationship problems

Cataract
Chronic painful eye

Risky behavior(behaviors known to increase the likelihood ofsubsequent illness or injury )Gaze paresis

Sleep problems

Glaucoma

Social withdrawal

ImmuneKeratitis

Suicidal ideation

Asplenia - functional

Lacrimal duct atrophy

Under-employment/Unemployment

Asplenia - surgical

Maculopathy

Psychosocial complication, other, specify:

Chronic hepatitis B

Nystagmus

Pulmonary

Chronic hepatitis C

Ocular nerve palsy

Acute respiratory distress syndrome

Chronic graft-versus-host disease (cGVHD)

Optic atrophy

Bronchiectasis

Chronic infection

Optic chiasm neuropathy

Bronchiolitis obliterans

Chronic sinusitis

Orbital hypoplasia

Chronic bronchitis

Decreased B cells

Papilledema

Interstitial pneumonitis

HIV infection

Papillopathy

Obstructive lung disease

Hypogammaglobulinemia

Poor prosthetic fit (related to enucleation)

Pulmonary fibrosis

Secretory IgA deficiency

Retinopathy

Restrictive lung disease

T cell dysfunction

Telangiectasias

Pulmonary complication, other, specify:

ObesityAge 2–20 yrs: BMI for age ≥ 95%ile
Age > 20 yrs, BMI ≥ 30

Gastrointestinal/Hepatic
Abdominal adhesions
Bowel obstruction
Cholelithiasis
Chronic enterocolitis

Strictures
Vitamin B12/folate/carotene deficiency
Gastrointestinal/hepatic complication, other,
specify:

COG LTFU Guidelines Appendix I – Page 29

Weakness

Depression

Version 6.0 – October 2023
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App I ContentsKey for Completing Summary of Cancer Treatment (Comprehensive)(cont)#17: Complications/Late Effects (by system)(cont)#17: Complications/Late Effects (by system)(cont)

Reproductive – Female

Urinary (cont)Adverse pregnancy outcome

Chronic urinary tract infection

Delivery complications

Dysfunctional voiding

Fetal malposition

Fanconi syndrome

Adverse pregnancy outcome (cont)

Glomerular injury

Low-birth weight infant

Hemorrhagic cystitis

Neonatal death

Hydrocele

Premature labor

Hydronephrosis

Pregnancy complications

Hyperfiltration

Spontaneous abortion

Hypertension

Breast tissue hypoplasia

Hypophosphatemic rickets

Dyspareunia

Proteinuria

Infertility

Renal dysfunction

Pelvic adhesions

Renal insufficiency

Pelvic floor dysfunction

Renal tubular acidosis

Premature ovarian insufficiency/premature menopause

Reservoir calculi

Psychosexual/sexual dysfunction

Urinary incontinence

Puberty - absence

Urinary tract obstruction

Puberty - delayed/arrested

Vesicoureteral reflux

Reduced fertility

Urinary complication, other, specify:

Symptomatic ovarian cysts

Other, specify:

Uterine vascular insufficiency

No late effects identified

Vaginal fibrosis/stenosis

Unknown

Spontaneous neobladder perforation

Vulvar scarring
Reproductive – female complication, other, specify:
Reproductive – Male
Anejaculation
Azoospermia
Ejaculatory dysfunction
Erectile dysfunction
Infertility
Oligospermia
Puberty - absence
Puberty - delayed/arrested
Reduced fertility
Retrograde ejaculation
Testosterone deficiency/insufficiency
Reproductive – male complication, other, specify:
Urinary
Asymptomatic bacteriuria
Bladder fibrosis

COG LTFU Guidelines Appendix I – Page 30

Version 6.0 – October 2023
Table of Contents

App I Contents

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Patient-Specific
Guideline
Identification
Tool

Version 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwide

Instructions:Patient-Specific Guideline Identification Tool (Version 6.0)
To determine Long-Term Follow-Up Guideline sections relevant to an individual patient:
1.

Place a check mark in the “Mark if Patient Received” column for each chemotherapy agent, radiation field, transplant type, surgery, or othertherapeutic modality that the patient received.

2.

Compile a list of all section numbers generated during step 1. Include the following sections as applicable:–

Sections 1 - 7

Applicable to all patients–

Section 8

Patients diagnosed before 1972–

Section 9

Patients diagnosed before 1993–

Section 10

Patients diagnosed between 1977 and 1985–

Section 11

All patients who received chemotherapy–

Sections 44, 45, 96

All patients who received radiation–

Sections 100 - 105

All patients who underwent hematopoietic cell transplant–

Section 164-165–

Section 100 is for males only–

Section 101 is for females only

Applicable to all patients3.

For patients who received radiation for which a minimum dose specification is indicated, follow the "Instructions for Radiation Dose Calculation" in Appendix I. Delete from your list those radiation section(s) for which the patient did not receive the minimum radiation exposure atwhich the section(s) become applicable.

4.

You now have a finalized list of all guideline sections applicable to this patient.

COG LTFU Guidelines Appendix I – Page 32

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Table of Contents

App I Contents

Patient-Specific Guideline Identification Tool
Applicable guideline sections indicated in bold/dark blue; M=Male; F=Female
Name:

Sex:

Cancer Diagnosis:

Date of Diagnosis:

 Sections 1–7 applicable to all patients

Prior to 1972:
Prior to 1993:
1977–1985:

M F

Date of Birth:
End Therapy Date: Section 8
 Section 9
 Section 10

LTFU guidelines are applicable topatients who are ≥ 2 years following
completion of cancer therapy.

CHEMOTHERAPY:  Yes  No
If yes:  Section 11 and applicable guidelines for specific chemotherapy agents below
Mark If
Patient
Received

Chemotherapy Agent

Applicable Guideline Sections

Asparaginase

Section 40

Bleomycin

Section 35

Busulfan**Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =Sections 12M, 13M, 14F, 15F, 16, 17, 18
mg/m2 = Cumulative dose x 8.823

Carboplatin: All doses

Sections 12M, 13M, 14F, 15F, 16, 23, 24

Carboplatin: Myeloablative dose (conditioning for HCT)

Section 22

Carmustine (BCNU)**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =Sections 12M, 13M, 14F, 15F, 16, 17

Chlorambucil**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =mg/m2 = Cumulative dose x 15

Sections 12M, 13M, 14F, 15F, 16
mg/m2 = Cumulative dose x 14.286

Cisplatin

Sections 12M, 13M, 14F, 15F, 16, 22, 23, 24

Cyclophosphamide**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =Sections 12M, 13M, 14F, 15F, 16, 19, 20
mg/m2 = Cumulative dose x 1

Cytarabine: Low dose IV (all single doses <1000 mg/m2), IO, IT, SQ

Section 26

Cytarabine: High dose IV (any single dose ≥1000 mg/m )Section 25

Dacarbazine (DTIC)

Sections 12M, 13M, 14F, 15F, 16

Dactinomycin

Section 36

Daunorubicin*
Cumulative dose =mg/m2
Doxorubicin isotoxic dose =Section 33, 34

2

mg/m2 = Cumulative dose x 0.5

Dexamethasone

Sections 37, 38, 39

Doxorubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 33, 34

Epirubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =mg/m2 = Cumulative dose x 1

Section 33, 34
mg/m2 = Cumulative dose x 0.67

Etoposide (VP16)

Section 43

Idarubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 33, 34

Ifosfamide**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =mg/m2 = Cumulative dose x 5

Sections 12M, 13M, 14F, 15F, 16, 19, 21
mg/m2 = Cumulative dose x 0.244

COG LTFU Guidelines Appendix I – Page 33

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Table of Contents

App I Contents

Patient-Specific Guideline Identification Tool (cont)Mark If
Patient
Received(cont)

Chemotherapy Agent (cont)

Applicable Guideline Sections (cont)Sections 12M, 13M, 14F, 15F, 16, 17

Lomustine (CCNU)**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =mg/m = Cumulative dose x 16
2

Sections 12M, 13M, 14F, 15F, 16

Mechlorethamine**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =mg/m2 = Cumulative dose x 100

Sections 12M, 13M, 14F, 15F, 16

Melphalan**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =mg/m2 = Cumulative dose x 40

Mercaptopurine (6MP)

Section 27

Methotrexate: High dose IV, Low dose IV, IM, PO

Sections 28, 29, 30

Methotrexate: High dose IV, IO, IT

Sections 31, 32

Mitoxantrone*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 33, 34
mg/m2 = Cumulative dose x 10

Prednisone

Sections 37, 38, 39

Procarbazine**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =Sections 12M, 13M, 14F, 15F, 16
mg/m2 = Cumulative dose x 0.857

Temozolomide

Sections 12M, 13M, 14F, 15F, 16

Teniposide (VM26)

Section 43

Thioguanine (6TG)

Section 27

Thiotepa**
Cumulative dose =mg/m2
Cyclophosphamide isotoxic dose =Sections 12M, 13M, 14F, 15F, 16
mg/m2 = Cumulative dose x 50

Vinblastine

Sections 41, 42

Vincristine

Sections 41, 42*Instructions for Anthracycline Dose Calculation: Use formulas below to convert to doxorubicin isotoxic equivalents prior to calculating total cumulative anthracycline dose:

Daunorubicin – multiply total dose x 0.5
Idarubicin – multiply total dose x 5

Doxorubicin – multiply total dose x 1
Mitoxantrone – multiply total dose x 10

Epirubicin – multiply total dose x 0.67**Instructions for Cyclophosphamide Dose Calculation: Use formulas below to convert to cyclophosphamide isotoxic equivalents prior to calculating total cumulative
cyclophophamide dose:

BCNU – multiply total dose x 15
Busulfan – multiply total dose x 8.823
Cyclophosphamide – multiply total dose x 1 Ifosfamide – multiply total dose x 0.244
Mechlorethamine – multiply total dose x 100 Melphalan – multiply total dose x 40
Thiotepa – multiply total dose x 50

Chlorambucil – multiply total dose x 14.286
CCNU – multiply total dose x 16
Procarbazine – multiply total dose x 0.857

Note: There is a paucity of literature to support isotoxic dose conversion; however, the above conversion factors may be used for convenience in order to gauge
screening frequency. Clinical judgment should ultimately be used to determine indicated screening for individual patients.
RADIATION:  Yes  No
If yes:  Sections 44, 45, 96 and applicable guidelines for specific radiation fields below
Mark If
Patient
Received

Radiation Field*

Dose

Applicable Guideline Sections

Any Radiation (not including TBI)

Any

Section 98

Head/Brain

Any

Sections 46, 47, 48, 49, 50, 51, 52, 53, 54M, 55F, 56, 57, 58M,
59F, 61, 62, 64, 65, 67, 68, 69, 70, 71

Head/Brain

Minimum dose specifications apply**

Sections 60, 63, 66

COG LTFU Guidelines Appendix I – Page 34

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Table of Contents

App I Contents

Patient-Specific Guideline Identification Tool (cont)
RADIATION:  Yes  No
If yes:  Sections 44, 45, 96 and applicable guidelines for specific radiation fields below
Mark If
Patient
Received(cont)

Radiation Field* (cont)

Dose (cont)

Applicable Guideline Sections (cont)

Neck

Any

Sections 64, 65, 67, 68, 69, 70, 71, 72, 79

Neck

Minimum dose specifications apply**

Section 66

AxillaAny

Sections 73F, 74F, 75, 76

Chest

Any

Sections 72, 73F, 74F, 75, 76, 79, 97

Chest

Minimum dose specifications apply**

Section 77

AbdomenAny

Sections 79, 80, 81, 82, 83, 84, 85, 86, 87, 97

Abdomen

Minimum dose specifications apply**

Sections 77, 78

PelvisAny

Sections 84, 85, 86, 88, 89, 92F, 93F, 94F, 95F

TestesAny

Sections 90M, 91M

Spine (whole)

Any

Sections 64, 65, 67, 68, 69, 70, 71, 72, 79, 84, 85, 86, 88, 89,
92F, 93F, 94F, 97

Spine (whole)

Minimum dose specifications apply**

Sections 66, 77

Spine (cervical)

Any

Sections 64, 65, 67, 68, 69, 70, 71, 79

Spine (cervical)

Minimum dose specifications apply**

Section 66

Spine (thoracic)

Any

Sections 72, 79, 97

Spine (thoracic)

Minimum dose specifications apply**

Section 77

Spine (lumbar)

Any

Sections 84, 85, 86, 97

Spine (sacral)

Any

Sections 84, 85, 86, 88, 89, 92F, 93F, 94F

TBI

Any

Sections 44, 45, 46, 47, 48, 53, 58M, 59F, 61, 64, 65, 67, 68,
69, 73F, 74F, 75, 76, 80, 81, 86, 87, 91M, 92F, 93F, 94F, 96

TBI

For cumulative dose calculation purposes
only; these sections are not applicable topatients who received TBI alone**

Sections 60, 63, 66, 77, 78*Instructions for Determining Radiation Field
Refer to "Radiation Fields Defined" in COG Long-Term Follow-Up Guidelines Appendix I pages 6-8 to determine applicable radiation fields. Note, for patients who received radiation
to the flank/hemiabdomen, include the pelvis only if the field extended below the iliac crest.
**Instructions for Radiation Dose Calculation:

Five sections of the COG Long-Term Follow-Up Guidelines (sections 60, 63, 66, 77, 78) include radiation dose specifications. These specifications indicate
the minimum dose of radiation that is believed (based on available evidence and the recommendations of the expert panel) to place patients sufficiently atrisk of the referenced late effect to recommend screening. For guideline sections that have a minimum specified dose, the following considerations apply indetermining the applicability of the section for a patient based on his/her radiation exposure.
Sections with minimum dose specifications are applicable to a patient only if:
1. Patient received radiation to any field(s) relevant to the particular guideline section at ≥ the specified minimum dose†OR
2. Patient received a combination of radiation to any relevant field(s)† plus relevant spinal radiation‡ and/or TBI, the sum of which is ≥ the specified minimum
dose†Total dose to each field should include boost dose, if given. If patient received radiation to more than one field relevant to a particular guideline section during
a single planned course of radiation treatment (excluding spinal radiation and TBI), the field that received the largest radiation dose should be used in
making the determination as to the applicability of the indicated guideline section(s). Exception: If patient received radiation to the same field at different
times (e.g., at time of diagnosis AND at relapse), these doses should be added together when considering the applicability of the indicated guideline section.
‡Use the largest dose of radiation delivered to the spinal field(s) specified in the guideline section.
For examples of radiation dose calculations, refer to "Radiation Dose Calculations" in COG Long-Term Follow-Up Guidelines Appendix I page 9.

COG LTFU Guidelines Appendix I – Page 35

Version 6.0 – October 2023
Table of Contents

App I Contents

Patient-Specific Guideline Identification Tool (cont)
Hematopoietic Cell Transplant:  Yes  No
If yes:  Sections 100M, 101F, 102, 103, 104, 105 and applicable guidelines below
Mark If
Patient
Received

Transplant Type

Chronic GVHD Status

Applicable Guideline Sections

Autologous

N/A

Section 99

Allogeneic

Without history of chronic GVHD

No additional guideline sections

Allogeneic

With history of chronic GVHD

Sections 106, 107, 108, 109, 110, 112, 113F, 114

Allogeneic

With currently active chronic GVHD

Section 111

Surgery:  Yes  No
If yes, applicable guidelines for specific surgical procedures below
Mark If
Patient
Received

Surgical Procedure

Applicable Guideline Sections

Amputation

Section 115

Central venous catheter

Section 116

Cystectomy

Sections 117, 142, 143, 144M, 145M, 146F

Enucleation

Section 118

Hysterectomy

Section 119F

Laparotomy

Section 120

Limb sparing procedure

Section 121

Nephrectomy

Sections 122M, 123F

Neurosurgery – brain (all types)

Sections 124, 125, 126, 127

Neurosurgery – brain (applies only to neurosurgery withpotential to affect the hypothalamic-pituitary axis)

Sections 128, 129

Neurosurgery – spinal cord

Sections 130, 131, 132M, 133F, 134

Oophoropexy

Section 135F

Oophorectomy – unilateral

Section 136F, 137F

Oophorectomy – bilateral

Section 138F

Orchiectomy – unilateral/partial

Sections 139M, 140M

Orchiectomy – bilateral

Section 141M

Pelvic surgery

Sections 142, 143, 144M, 145M, 146F

Splenectomy

Section 147

Thoracic surgery

Sections 148, 149

Thyroidectomy - total/partial

Section 150, 151

COG LTFU Guidelines Appendix I – Page 36

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Table of Contents

App I Contents

Patient-Specific Guideline Identification Tool (cont)
Other Therapeutic Modalities:  Yes  No
If yes, applicable guidelines for specific modalities below
Mark If
Patient
Received

Other Therapeutic Modality

Applicable Guideline Sections

Radioiodine therapy (I-131 thyroid ablation)

Sections 152, 153, 154

Systemic MIBG

Sections 155, 156, 157

Bioimmunotherapy (e.g., G-CSF, IL-2, erythropoietin)

Section 158

BCR-ABL tyrosine kinase inhibitors (e.g., imatinib, dasatinib)

Section 159, 160

Other targeted biologic therapies

Section 161

B-cell directed antibody-based therapies (e.g., rituximab)

Section 162

Other antibody-based immune therapies, including antibody drug
conjugates (e.g., blinatumomab, brentuximab vedotin, inotuzumab,
gemtuzomab ozogamicin, dinutuximab, naxitamab, pembrolizumab,
ipilimumab, nivolumab, atezolizumab)

Section 163

General Health Screening
All patients:

 Section 164, 165

COG LTFU Guidelines Appendix I – Page 37

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Table of Contents

App I Contents

Long-Term
Follow-Up
Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers

Section Number
Comparison
COG LTFU
Guidelines
Version 6.0 vs 5.0
Version 6.0
October 2023

Copyright 2023 © Children’s Oncology GroupAll rights reserved worldwide

Section Number Comparison
COG LTFU Guidelines Version 6.0 vs 5.0
Version
6.0

Version
5.0
Potential Late EffectVersion
6.0

Any Cancer Experience

Version
5.0
Potential Late Effect29

28

No known renal late effects related tomethotrexate

1

1

Adverse psychosocial/quality of life effects22

Mental health disorders

30

29

Hepatic dysfunction

3

3

Risky behavior

31

30

Neurocognitive deficits

4

4

Psychosocial disability due to pain

32

31

Clinical leukoencephalopathy

55

Fatigue; Sleep problems

33

32

Acute myeloid leukemia

66Limitations in healthcare and insurance
access34

33

Cardiac toxicity

35

34

Pulmonary toxicity

7

N/A

New to V6: Subsequent malignancy; Risk ofmalignancy in offspring

36

35

No known late effects related to dactinomycin

37

36

Reduced bone mineral density (BMD)38

37

Osteonecrosis (avascular necrosis)

39

38

Cataracts

40

39

No known late effects related to asparaginase

41

40

Peripheral sensory or motor neuropathy

42

41

Vasospastic attacks (Raynaud's phenomenon)

43

42

Acute myeloid leukemia

44

43

Subsequent benign or malignant neoplasm
occurring in or near radiation field

Blood/Serum Products
87

Chronic hepatitis B

98Chronic hepatitis C

109

HIV infection
Chemotherapy

11

10

Dental abnormalities

12

11

Testicular hormonal dysfunction

13

12

Impaired spermatogenesis

14

13

Ovarian hormone deficiencies

15

14

Diminished ovarian reserve (DOR), previously
Reduced ovarian follicular pool45

44

Dermatologic toxicity other than neoplasms

46

45

Brain tumor (benign or malignant)

16

15

Acute myeloid leukemia; Myelodysplasia

47

46

Neurocognitive deficits

17

16

Pulmonary fibrosis48

47

Clinical leukoencephalopathy

18

17

Cataracts

49

48

Cerebrovascular complications

19

18

Urinary tract toxicity

20

19

Bladder malignancy

50

49

Craniofacial abnormalities

21

20

Renal toxicity

51

50

Chronic sinusitis

22

21

Ototoxicity

52

51

Overweight; Obesity

23

22

Peripheral sensory neuropathy

53

52

Growth hormone deficiency

24

23

Renal toxicity

54

53

Precocious puberty (male)

25

24

Neurocognitive deficits

55

54

Precocious puberty (female)26

25

No known late effects related to cytarabine(low dose IV, IO, IT, SQ)

56

55

Hyperprolactinemia

57

56

Central hypothyroidism

27

26

Hepatic dysfunction; Sinusoidal obstruction
syndrome (SOS)

58

57

Gonadotropin deficiency (male)59

58

Gonadotropin deficiency (female)28

27

Update in V6: No known BMD late effects
related to methotrexate (IV, IM, PO)

60

59

Central adrenal insufficiency

61

60

Cataracts

Radiation

COG LTFU Guidelines Appendix I – Page 39

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Table of Contents

App I Contents

Section Number Comparison
COG LTFU Guidelines Version 6.0 vs 5.0 (cont)Version
6.0

Version
6.0

Version
5.0
Potential Late EffectVersion
5.0
Potential Late Effect62

61

Ocular toxicity

95

94

Vaginal fibrosis/stenosis

63

62

Ototoxicity

96

95

Musculoskeletal growth problems

64

63

Xerostomia; Salivary gland dysfunction

97

96

Scoliosis/Kyphosis

65

64

Dental abnormalities; Temporomandibular
joint dysfunction

98

97

Radiation-induced fracture66

65

Osteoradionecrosis of the jaw

67

66

Thyroid nodules

68

67

Thyroid cancer

69

68

Hypothyroidism

70

69

Hyperthyroidism

71

70

Carotid artery disease72

71

Subclavian artery disease

73

72

Breast cancer

74

73

Breast tissue hypoplasia

75

74

Pulmonary toxicity

7675

Lung cancer

77

76

Cardiac toxicity

78

77

Functional asplenia

79

78

Esophageal stricture

80

79

Impaired glucose metabolism/diabetes
mellitus

81

80

Dyslipidemia

82

81

Hepatic toxicity

83

82

Cholelithiasis

115

114

Amputation-related complications

84

83

Bowel obstruction

116

115

85

84

Chronic enterocolitis; Fistula; Strictures

86

85

Colorectal cancer

Thrombosis; Vascular insufficiency; Infectionof retained cuff or line tract; Post-thrombotic
syndrome

87

86

Renal toxicity

117

116

Cystectomy-related complications

88

87

Urinary tract toxicity

118

117

89

88

Bladder malignancy

Impaired cosmesis; Poor prosthetic fit; Orbital
hypoplasia

90

89

Testicular hormonal dysfunction

119

118

91

90

Impaired spermatogenesis

Pelvic floor dysfunction; Urinary incontinence;
Sexual dysfunction (female)

92

91

Ovarian hormone deficiencies

120

119

Adhesions; Bowel obstruction

93

92

Diminished ovarian reserve, previously
Reduced ovarian follicular pool

121

120

Complications related to limb sparing
procedure

94

93

Uterine vascular insufficiency

122

121

Hydrocele; Renal toxicity (male)

Hematopoietic Cell Transplant99

98

Acute myeloid leukemia; Myelodysplasia

100

99

Solid tumors (male)

101

100

Solid tumors (female)

102

101

Hepatic toxicity

103

102

Osteonecrosis (avascular necrosis)

104

103

Reduced bone mineral density

105

104

Renal toxicity

106

105

Dermatologic toxicity

107

106

Xerophthalmia (keratoconjunctivitis sicca)

108

107

Oral toxicity

109

108

Pulmonary toxicity

110

109

Immunologic complications

111

110

Functional asplenia

112

111

Esophageal stricture

113

112

Vulvar scarring; Vaginal fibrosis/stenosis

114

113

Joint contractures
Surgery

COG LTFU Guidelines Appendix I – Page 40

Version 6.0 – October 2023
Table of Contents

App I Contents

Section Number Comparison
COG LTFU Guidelines Version 6.0 vs 5.0 (cont)Version
6.0

Version
5.0
Potential Late EffectVersion
6.0

Version
5.0
Potential Late Effect

123

122

Renal toxicity (female)

155

152

Hypothyroidism

124

123

Neurocognitive deficits

156

153

Thyroid nodules

125

124

Motor and/or sensory deficits

157

154

Thyroid cancer

126

125

Seizures

158

155

127

126

Hydrocephalus; Shunt malfunction

Insufficient information currently available
regarding late effects of biologic agents

128

127

Overweight; Obesity

159

N/A

New to V6: Growth attenuation

129

128

Diabetes insipidus

160

N/A

New to V6: Hypothyroidism

130

129

Neurogenic bladder; Urinary incontinence

161

N/A

131

130

Neurogenic bowel; Fecal incontinence

New to V6: Insufficient information currently
available regarding late effects of biologic
agents132

131

Psychosexual dysfunction (male)

162

N/A

New to V6: Immunologic complications

133

132

Psychosexual dysfunction (female)

163

N/A

134

133

Scoliosis/Kyphosis

New to V6: Insufficient information currently
available regarding late effects of biologic
agents135

134

Oophoropexy-related complication

136

135

Ovarian hormone deficiencies

N/A

156

Breast cancer (female)

137

136

Diminished ovarian reserve, previously
Reduced ovarian follicular pool

N/A

157

Cervical cancer (female)

N/A

158

Colorectal cancer

N/A

159

Endometrial cancer (female)

N/A

160

Lung cancer

N/A

161

Oral cancer

N/A

162

Prostate cancer (male)

N/A

163

Skin cancer

N/A

164

Testicular cancer (male)

138

137

Ovarian hormone deficiencies; Loss of ovarianfollicular pool

139

138

Testicular hormonal dysfunction

140

139

Impaired spermatogenesis

141

140

Testosterone deficiency; Azoospermia

142

141

Urinary incontinence; Urinary tract obstruction

143

142

Fecal incontinence

144

143

Psychosexual dysfunction

145

144

Sexual dysfunction (anatomic); Infertility

146

145

Sexual dysfunction

147

146

Asplenia

148

147

Pulmonary dysfunction

149

148

Scoliosis/Kyphosis

150

149

Hypothyroidism

151

N/A

New to V6: Hypothyroidism

Cancer Screening Guidelines

General Health Screening
164

165

General health

165

N/A

New to V6: Vaccinations

Other Therapeutic Models
152

150

Lacrimal duct atrophy

153

151

Hypothyroidism

154

N/A

New to V6: Xerostomia; Salivary gland
dysfunction; Chronic sialadenitis

COG LTFU Guidelines Appendix I – Page 41

Version 6.0 – October 2023
Table of Contents

App I Contents