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

Appendix I

Materials
for ClinicalApplication

Version 5.0
October 2018

Copyright 2018 © Children’s Oncology GroupAll rights reserved worldwide

Contents
Appendix I: Materials for Clinical Application of LTFU Guidelines

Page

Reference Materials

3

Abbreviations

5

Chemotherapy Agents

7

Radiation Fields Defined

8

Radiation Dose Calculations

11

Guideline Radiation Sections by Field

12

Guideline Radiation Sections by Potential Impact

13

Total Body Irradiation (TBI) Related Potential Late Effects
Appeal Letter Following Denial of Insurance Claims for Survivorship Care

16
17

Instructions

19

Template for Letter from Patient, Parent, or Guardian20

Template for Letter from Long-Term Follow-Up Clinician
Summary of Cancer Treatment

21
23

Instructions

25

Template for Summary of Cancer Treatment (Abbreviated)

27

Template for Summary of Cancer Treatment (Comprehensive)28

Key for Completing Summary of Cancer Treatment (Comprehensive)

30

Patient-Specific Guideline Identification Tool

37

Instructions

39

Patient-Specific Guideline Identification Tool (Version 5.0)

40

Section Number Comparison - COG LTFU Guidelines Version 4.0 vs 5.0

COG LTFU Guidelines Appendix I – Page 1

45

Version 5.0 – October 2018

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

Reference
Materials

Version 5.0
October 2018

Copyright 2018 © Children’s Oncology GroupAll rights reserved worldwide

Abbreviations
Abbreviation

Definition

Abbreviation

Definition

AAP

American Academy of Pediatrics

DXA

Dual energy x-ray absorptiometry

ABR

Auditory brainstem response

ECHO

Echocardiogram

ACIP

Advisory Committee on Immunization Practices

EKG

Electrocardiogram

ACS

American Cancer Society

EIA

Enzyme immunoassay

AHA

American Heart Association

FAP

Familial adenomatous polyposis

ALL

Acute lymphoblastic leukemia

FM

Frequency modulated

ALT

Alanine aminotransferase

FNA

Fine needle aspirate

AMH

Anti-Mullerian hormone

FNH

Focal nodular hyperplasia

AML

Acute myeloid leukemia

FSH

Follicle stimulating hormone

AST

Aspartate aminotransferase

G-CSF

Granulocyte colony stimulating factor

ATG

Anti-thymocyte globulinGH

Growth hormone

ATM

Ataxia telangiectasia cancer susceptibility gene(located on chromosome 11)GI

Gastrointestinal

gm

Gram

AVN

Avascular necrosis

GVHD

Graft versus host disease

BMD

Bone mineral density

Gy

Gray

BMI

Body mass index

HbA1c

Hemoglobin A1c

BRCA1

Breast cancer susceptibility gene 1 (located on
chromosome 17)

HBcAb

Hepatitis B core antibody

HBsAg

Hepatitis B surface antigen

Breast cancer susceptibility gene 2 (located on
chromosome 13)

HCT

Hematopoietic cell transplant

HCV

Hepatitis C virus

BUN

Blood urea nitrogen

HDL

High-density lipoproteinsCa

Calcium

HIB

Haemophilus influenzae type B

CBC

Complete blood countHIV

Human immunodeficiency virus

CCG

Children’s Cancer GroupHLA

Human leukocyte antigen

CDC

Centers for Disease Control

HNPCC

Hereditary nonpolyposis colorectal cancer

cGVHD

Chronic graft versus host disease

HPF

High power field

Cl

Chloride

HPV

Human papillomavirus

CNS

Central nervous systemht

HeightCO2

Carbon dioxide

Hz

Hertz

COG

Children’s Oncology GroupIBD

Inflammatory bowel disease

CT

Computed tomography

K

PotassiumdB

DecibelI-131

Iodine 131 radioisotope

DES

Diethylstilbestrol

IgA

Immunoglobulin A

DLCO

Diffusion capacity of carbon monoxide

IL-2Interleukin-2

DTI

Diffusion-tensor imaging

IM

Intramuscular

DWI

Diffusion-weighted imaging

IO

Intra-Ommaya

BRCA2

COG LTFU Guidelines Appendix I – Page 5

Version 5.0 – October 2018

Abbreviations (cont)Abbreviation

Definition

Abbreviation

Definition

IQ

Intelligence quotient

RUQ

Right upper quadrant

IT

Intrathecal

SCUBA

Self-contained underwater breathing apparatus

IU

International unit

SDStandard deviation

IV

Intravenous

SOS

Sinusoidal obstruction syndrome

IVIG

Intravenous immunoglobulin

T4

Thyroxine

kg

Kilogram

TBI

Total body irradiation

KUB

Kidneys, ureters, bladder radiograph

TPN

Total parenteral nutrition

LH

Luteinizing hormone

TSH

Thyroid stimulating hormone

LV

Left ventricular

U

Units

m2

Square meter

USPSTF

United States Preventive Services Task ForceMDS

Myelodysplastic syndrome

V-A

Ventriculoatrial

MIBG

Iodine-131-meta-iodobenzylguanidine

VOD

Veno-occlusive diseasemg

Milligram

V-P

Ventriculoperitoneal

Mg

Magnesium

V-V

Ventriculovenus

MOPP

Mechlorethamine, Oncovin, Procarbazine,
Prednisone

VZIG

Varicella zoster immunoglobulin

WAGR

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

wt

WeightMR

Magnetic resonance

MRI

Magnetic resonance imaging

Na

SodiumNF1

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

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

QTc

Corrected QT interval

RB1

Retinoblastoma cancer susceptibility gene (locatedon chromosome 13)

RBC

Red blood cell

COG LTFU Guidelines Appendix I – Page 6

Version 5.0 – October 2018

Chemotherapy Agents
Generic Name

Additional Name(s)AsparaginaseElspar®

Classification
EnzymeErwinia asparaginase
Kidrolase®
L-asparaginase
Oncaspar®
PEG-asparaginase

Generic Name

Additional Name(s)Classification

Ifosfamide

Ifex®

Alkylating agent

Lomustine

CeeNU®

Alkylating agent

CCNU
Mechlorethamine

Mustargen®
Nitrogen Mustard

Alkylating agent

Bleomycin

Blenoxane®

Anti-tumor antibiotic

Melphalan

Alkeran®

Alkylating agent

BusulfanBusulfex®

Alkylating agent

Mercaptopurine

6-Mercaptopurine
6MP
Purinethol®

Antimetabolite

Methotextrate

Amethopterin
Folex®
Mexate®
Trexall®

Antimetabolite

Mitoxantrone

Novantrone®

Anthracycline
antibiotic

Prednisone

Deltasone®
Methylprednisolone
Prednisolone

Corticosteroid

Procarbazine

Matulane®
Natulan®

Alkylating agent

Temozolomide

Temodal®
Temodar®

Non-classicalalkylator

Teniposide

VM26
Vumon®

Epipodophyllotoxin

Thioguanine

Lanvis®
Tabloid®
6-Thioguanine
6TG

Antimetabolite

Thiotepa

Thioplex®

Alkylating agent

Busulphan
Myleran®
Carboplatin

CBDCA
Paraplatin®

Heavy metal

CarmustineBCNU
BiCNU®

Alkylating agent

Chlorambucil

Leukeran®

Alkylating agent

Cisplatin

CDDP
Cisplatinum
Platinol®

Heavy metal

Cyclophosphamide

CPM
Cytoxan®
Neosar®
Procytox®

Alkylating agent

Ara-C
Cytosar®
Cytosar-U®
Cytosine arabinoside

Antimetabolite

Dacarbazine

DTIC
DTIC-Dome®

Non-classicalalkylator

Dactinomycin

Actinomycin-D
Cosmegen®

Anti-tumor antibiotic

Daunorubicin

Cerubidine®

Anthracycline
antibiotic

Vinblastine

VBL
Velban®
Velbe®

Plant alkaloid

Vincristine

Oncovin®
VCR
Vincasar®
Vincrex®

Plant alkaloid

Cytarabine

Daunomycin
DaunoXome®
Dexamethasone

Decadron®

Corticosteroid

Doxorubicin

Adriamycin®
Doxil®
Rubex®

Anthracycline
antibiotic

Epirubicin

Ellence®
Pharmorubicin PFS®

Anthracycline
antibiotic

Etoposide

VePesid®
VP16

Epipodophyllotoxin

Idarubicin

Idamycin®

Anthracycline
antibiotic

COG LTFU Guidelines Appendix I – Page 7

Version 5.0 – October 2018

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 (STLI)

Mantle + paraaortic + splenic

Neck
AxillaChest
AbdomenInverted Y

Paraaortic + pelvic ± splenic

AbdomenPelvisTotal lymphoid (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 8

Version 5.0 – October 2018

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 thepelvis. 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

COG LTFU Guidelines Appendix I – Page 9

Version 5.0 – October 2018

Radiation Fields Defined (cont)Version 5.0 fields shown in black boxes

COG LTFU Guidelines Appendix I – Page 10

Version 5.0 – October 2018

Radiation Dose Calculations
Instructions for Radiation Dose Calculation:
Five sections of the COG Long-Term Follow-Up Guidelines (sections 59, 62, 65, 76, 77) 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 Relevant
specification for radiation fields
screening

Patient's relevant
radiation fields

Step 1

Step 2

Section 65,
osteoradionecrosisof the jaw≥40 GyRadiation at diagnosis:• Head/brain: 24 Gy• Neck: 18 Gy
Radiation at relapse:• Head/brain: 12 Gy• TBI: 12 Gy

24 Gy

24 Gy

Head/Brain
Neck
Spine (cervical)
Spine (whole)
TBI

Step 3

Step 4N/A

36 Gy

Conclusion

48 Gy+ 12 Gy+ 12 Gy

36 Gy

48 Gy

Guideline
65 isapplicable

Step 3

Step 4

Conclusion

6 Gy

N/A

18 Gy

Example #2
Guideline Information

Patient Information

Guideline section

Minimum dose Relevant
specification for radiation fields
screening

Patient's relevant
radiation fields

Step 1

Step 2

Section 76, cardiac
toxicity≥15 GyRadiation at diagnosis:• Chest: 6 Gy
Radiation at relapse:• Spine (whole):
12 Gy

6 Gy

N/A

Chest
AbdomenSpine (thoracic)
Spine (whole)TBI

COG LTFU Guidelines Appendix I – Page 11+ 12 Gy
18 Gy

Guideline
76 isapplicable

Version 5.0 – October 2018

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

COG LTFU Guidelines Appendix I – Page 12

Version 5.0 – October 2018

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

43*

Secondary benign or malignant neoplasm

44*

Dermatologic toxicity

45*

Brain tumor (benign or malignant)46*

Neurocognitive deficits

47*

Clinical leukoencephalopathy

48

Cerebrovascular complications

49

Craniofacial abnormalities

50

Chronic sinusitis

51

Overweight; Obesity

52*

Growth hormone deficiency

53M

Precocious puberty (male)

54F

Precocious puberty (female)55

Hyperprolactinemia

56

Central hypothyroidism

57M*

Gonadotropin deficiency (male)

58F*

Gonadotropin deficiency (female)≥30Gy**

59

Central adrenal insufficiency

Any

60*

Cataracts

61

Ocular toxicity

Brain/Cranium

Neuroendocrine
Axis

Eye

Head/Brain

Head/Brain

Head/Brain

Any

Any

Ear

Head/Brain≥30Gy**

62

Ototoxicity

Oral Cavity

Head/Brain
Neck
Spine (cervical, whole)

Any

63*

Xerostomia; Salivary gland dysfunction

64*

Dental abnormalities; Temporomandibular joint
dysfunction≥40 Gy**65

Osteoradionecrosis of the jaw

Any

66*

Thyroid nodules

67*

Thyroid cancer

68*

Hypothyroidism

69

Hyperthyroidism

70

Carotid artery disease71

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 13

Version 5.0 – October 2018

Guideline Radiation Sections by Potential Impact (cont)
Potential Impact
BreastSectionNumbers
72F*

Potential Late Effects
Breast cancer

73F*

Breast tissue hypoplasia

74*

Pulmonary toxicity

75*

Lung cancer≥15 Gy**76

Cardiac toxicity

Abdomen≥40 Gy**77

Functional asplenia

Neck
Chest
AbdomenSpine (cervical, thoracic, whole)

Any

78

Esophageal stricture

AbdomenAny

79*

Impaired glucose metabolism/diabetes mellitus

80*

Dyslipidemia

81

Hepatic toxicity

82

Cholelithiasis

83

Bowel obstruction

84

Chronic enterocolitis; Fistula; Strictures

85*

Colorectal cancer

FieldsChext
Axilla

Dose
Any

Chest
Axilla

Any

Heart

Chest
AbdomenSpine (thoracic, whole)

SpleenGI/Hepatic
SystemLungs

AbdomenPelvisSpine (lumbar, sacral, whole)
Urinary Tract

Any

AbdomenAny

86*

Renal toxicity

PelvisSpine (sacral, whole)

Any

87

Urinary tract toxicity

88

Bladder malignancy

Male
Reproductive
SystemTestesAny

89M

Testicular hormonal dysfunction

90M*

Impaired spermatogenesis

FemaleReproductive
SystemPelvisSpine (sacral, whole)

91F*

Ovarian hormone deficiencies

92F*

Reduced ovarian follicular pool

93F*

Uterine vascular insufficiency

Musculoskeletal
SystemAny

PelvisAny

94F

Vaginal fibrosis/stenosis

Any radiation

Any

95*

Musculoskeletal growth problems

Chest
AbdomenSpine (thoracic, lumbar, whole)

Any

96

Scoliosis/Kyphosis

Any radiation

Any

97

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

COG LTFU Guidelines Appendix I – Page 14

Version 5.0 – October 2018

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

COG LTFU Guidelines Appendix I – Page 15

Version 5.0 – October 2018

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

43

Both

Secondary benign or malignant neoplasm occurring in or near radiation field

44

Both

Dermatologic toxicity

45

Both

Brain tumor (benign or malignant)

46

Both

Neurocognitive deficits

47

Both

Clinical leukoencephalopathy

52

Both

Growth hormone deficiency

57

Male

Gonadotropin deficiency

58

FemaleGonadotropin deficiency

60

Both

Cataracts

63

Both

Xerostomia; Salivary gland dysfunction

64

Both

Dental abnormalities; Temporomandibular joint dysfunction

66

Both

Thyroid nodules

67

Both

Thyroid cancer

68

Both

Hypothyroidism

72

FemaleBreast cancer

73

FemaleBreast tissue hypoplasia

74

Both

Pulmonary toxicity

75

Both

Lung cancer

79

Both

Impaired glucose metabolism/diabetes mellitus

80

Both

Dyslipidemia

85

Both

Colorectal cancer

86

Both

Renal toxicity

90

Male

Impaired spermatogenesis

91

FemaleOvarian hormone deficiencies

92

FemaleReduced ovarian follicular pool

93

FemaleUterine vascular insufficiency

95

Both

Musculoskeletal growth problems

COG LTFU Guidelines Appendix I – Page 16

Version 5.0 – October 2018

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

Appeal Letter
Following Denialof Insurance
ClaimsVersion 5.0
October 2018

Copyright 2018 © 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.

COG LTFU Guidelines Appendix I – Page 19

Version 5.0 – October 2018

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 20

Version 5.0 – October 2018

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 21

Version 5.0 – October 2018

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

Summaryof Cancer
Treatment

Version 5.0
October 2018

Copyright 2018 © 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 10-42), 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 33 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 25

Version 5.0 – October 2018

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 43-97),• 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
114–149), 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) or systemic MIBG (in therapeutic doses)• 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 (and 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 26

Version 5.0 – October 2018

Summary of Cancer Treatment (Abbreviated)
Demographics
Sex  M  F

NameDate of Birth

Cancer Diagnosis
Diagnosis

Date of Diagnosis

Chemotherapy

 Yes

 No

Date Therapy Completed

If yes, provide information below
Additional Information†

Drug Name†Anthracyclines: Include cumulative dose in mg/m2 (see section 33 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

If yes, provide information below

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

COG LTFU Guidelines Appendix I – Page 27

Laterality (if applicable)

 Yes

 Yes

 No

 No
Date prepared:

Version 5.0 – October 2018

Summary of Cancer Treatment (Comprehensive)
Superscript numbers correspond with lists in "Key for Completing Summary of Cancer Treatment Form"
Demographics
Name
Sex  M  F

Race/Ethnicity1

Date of BirthSS#

COG Reg #Address

Phone

Alternate contact

Relationship

Phone

Cancer Diagnosis
Diagnosis2
Date of diagnosis

Age at diagnosis

Date therapy completed
Laterality  Right  Left  NA

Sites involved/stage/diagnostic details
Hereditary/congenital history3
Pertinent past medical history
Institution
Relapse(s)MD/APN Yes

 No

Medical record #If yes, provide information below

Date of diagnosis

Age at diagnosis

Date therapy completed
Laterality  Right  Left  NA

Sites involved/stage/diagnostic details
Subsequent malignant neoplasm(s)

 Yes

 No

If yes, provide information below

Type4
Date of diagnosis

Age at diagnosis

Date therapy completed
Laterality  Right  Left  NA

Sites involved/stage/diagnostic details
Cancer Treatment Summary
Protocol(s) YesAcronym/Number

Chemotherapy

 No

If yes, provide information below

Title/Description

 Yes

 No

Initiated

Completed

On-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 33 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 28

Version 5.0 – October 2018

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

Site/Field8

Laterality

 No

If yes, provide information below
Type9Start/Stop
Dates

Fractions

Institution

Dose perFraction (Gy)*

Boost Site10

Initial
Dose (Gy)*

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) Yes

Hematopoietic Cell Transplant
Type11

 No

If yes, provide information below
Source12

Tandem?
 Yes

 No

Institution

Transplant physician

Graft-Versus-Host Disease (GVHD) Prophylaxis/Treatment (for transplant patients only)
Type14

 YesFirst Dose Yes

Was the patient ever diagnosed with chronic GVHD?
Surgery

Conditioning Regimen13

Date of Infusion

 Yes

 No

Procedure15

 No

 No

If yes, provide information below

Last Dose

Does the patient currently have active chronic GHVD?

 Yes

 No

If yes, provide information below
Date

Other Therapeutic Modalities

Site (if applicable)

 Yes

 No

Laterality (if applicable)

Institution/Surgeon

If yes, provide information below

Therapy16

Route6

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

Additional Information/Comments

 Yes

Date resolved

 No

Status Active Resolved

 Active Resolved

 Active Resolved

 Active Resolved

If yes, provide information below
Date

Status Active
 No

 Resolved

If yes, provide information below

Summary prepared by:Date prepared:

Summary updated by:Date updated:

COG LTFU Guidelines Appendix I – Page 29

Version 5.0 – October 2018

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 30

Version 5.0 – October 2018

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’s 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

mg/m2

Fluorouracil

units/m2

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/eye
Specify:  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

COG LTFU Guidelines Appendix I – Page 31

Version 5.0 – October 2018

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 –Conditioning Regimen (cont)Chest (thorax)

None

Melphalan

Whole lungSpecify:  Right  Left  Bilateral

Unknown

Thiotepa

Add comment:

TBI

Mediastinal#9: Radiation TypeHCT conditioning regimen, other, specify:

Chest, other, specify:

Brachytherapy

Unknown

Abdomen

Conformal#14: GVHD Prophylaxis/Treatment

Hepatic

External beam (conventional)

ATG

Renal
Specify:  Right  Left  Bilateral

IMRT

Cyclosporine

Proton beam

Methotrexate

Upper quadrant
Specify:  Right  Left  Bilateral

Stereotactic

MMF (mycophenolate mofetil)

Radiation type, other, specify:

Prednisone

None

PUVA

Paraaortic

Unknown

Sirolimus

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

#10: Radiation Boost

Tacrolimus

Tumor bed, specify location:

GVHD prophylaxis/treatment, other, specify:

Radiation boost location, other, specify:

None

PelvisNone

Unknown

PelvicUnknown#15: Surgery

Vaginal

Add comment:

Prostate#11: Hematopoietic Cell Transplant – Type

Amputation, specify site:
Specify:  Right  Left  Bilateral

Bladder

Autologous

Central venous catheter

Iliac

Matched related

Cystectomy

Inguinal

Mismatched related

Enucleation
Specify:  Right  Left  Bilateral

FemoralHaploidentical related

SpleenSpecify:  Partial  Entire

TesticularSpecify:  Right  Left  Bilateral
Extremity
UpperSpecify:  Right  Left  BilateralSpecify:  Proximal  Distal  Entire

Syngeneic
Matched unrelated
HCT type, other, specify:

Hysterectomy
Laparotomy
Limb sparing procedure, specify site:
Specify:  Right  Left  Bilateral

Unknown#12: Hematopoietic Cell Transplant – Source
Bone marrow

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

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

Peripheral blood stem cells

Total Body Irradiation (TBI)

Unknown

Combination Fields:
Mantle#13: Hematopoietic Cell Transplant –Conditioning Regimen

Oophorectomy
Specify:  Right  Left  Bilateral

Mini-mantle

ATG

Extended mantle

Busulfan

Inverted Y

Carmustine (BCNU)

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

Whole abdomen

Cyclophosphamide

Pelvic surgery

Total lymphoid irradiation (TLI)

Etoposide

Thoracic surgery*

Subtotal lymphoid irradiation (STLI)

Fludarabine

Splenectomy

COG LTFU Guidelines Appendix I – Page 32

Cord blood
HCT source, other, specify:

Neurosurgery – spinal cord
Oophoropexy

Version 5.0 – October 2018

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

Thrombosis

Malocclusion

Valvular disease

Microdontia

Vascular insufficiency

Osteoradionecrosis of the jaw

Cardiovascular complication, other, specify:

Periodontal disease

Central Nervous System (CNS)

Root thinning/shortening

AtaxiaSalivary gland dysfunction

Cavernomas

Temporomandibular joint dysfunction

Chronic pain, central neuropathic

Tooth/root agenesis

Clinical leukoencephalopathy

Xerostomia

Dysarthria

Dental complication, other, specify:

Dysphagia

Dermatologic

Hemiparesis

Altered skin pigmentation

Hydrocephalus

Nail dystrophy

Movement disorders

Permanent alopecia

Moyamoya

Sclerodermatous changes

Neurocognitive deficits

Skin fibrosis

Academic fluency

Telangiectasias

Behavioral change

Vitiligo

Diminished IQ

Dermatologic complication, other, specify:

Executive function (planning and organization)

Endocrine/Metabolic

Fine motor dexterity

Central adrenal insufficiency

Language

Diabetes insipidus

Learning deficits in math and reading(particularly reading comprehension)

Dyslipidemia

Tinnitus

Memory (particularly visual, sequencing,temporal memory)

Growth hormone deficiency

Tympanosclerosis

Processing speed

VertigoSustained attention

Auditory complication, other, specify:

Visual-motor integration#16: Other Therapeutic Modalities
Systemic Radiation
Radioiodine therapy (I-131 thyroid ablation)
Systemic MIBG (in therapeutic doses)
Systemic radiation, other, specify:
Bioimmunotherapy
Hematopoietic growth factors:
G-CSF
Erythropoietin
Thrombopoietin
Interferon:
Alpha interferon
Gamma interferon
Interleukin:
IL-2
IL-11
Other, specify:
Monoclonal antibody, specify type:
Retinoic acid, specify type:
Bioimmunotherapy, other, specify:
Other therapeutic modality, specify:
None
Unknown#17: Complications/Late Effects (by system)
Auditory
Conductive hearing loss
Eustachian tube dysfunction
Otosclerosis
Sensorineural hearing loss

Cardiovascular

Neurogenic bladder

Arrhythmia

Neurogenic bowel

COG LTFU Guidelines Appendix I – Page 33

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

Version 5.0 – October 2018

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)

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

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 )Gastrointestinal/Hepatic
Abdominal adhesions
Bowel obstruction
Cholelithiasis
Chronic enterocolitis

Strictures
Vitamin B12/folate/carotene deficiency

Weakness

Depression

Gaze paresis

Gastrointestinal/hepatic complication, other,
specify:

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:

COG LTFU Guidelines Appendix I – Page 34

Version 5.0 – October 2018

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

Spontaneous neobladder perforation

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

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 35

Version 5.0 – October 2018

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

Patient-Specific
Guideline
Identification
Tool

Version 5.0
October 2018

Copyright 2018 © Children’s Oncology GroupAll rights reserved worldwide

Instructions:Patient-Specific Guideline Identification Tool (Version 5.0)
To determine Long-Term Follow-Up Guideline sections relevant to an individual patient:
1.
2.

3.

4.

Place a checkmark in the “Mark if Patient Received” column for each chemotherapy agent, radiation field, transplant type, surgery, or othertherapeutic modality that the patient received.
Compile a list of all section numbers generated during step 1. Include the following sections as applicable:– Sections 1 - 6
Applicable to all patients– Section 7
Patients diagnosed before 1972
– Section 8
Patients diagnosed before 1993
– Section 9
Patients diagnosed between 1977 and 1985
– Section 10
All patients who received chemotherapy– Sections 43, 44, 95
All patients who received radiation– Sections 99 - 104
All patients who underwent hematopoietic cell transplant– Section 99 is for males only
– Section 100 is for females only
– Sections 156 - 164
Applicable to all patients– Sections 162, 164 are for males only
– Sections 156, 157, 159 are for females only
– Section 165
Applicable to all patients
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.
You now have a finalized list of all guideline sections applicable to this patient.

COG LTFU Guidelines Appendix I – Page 39

Version 5.0 – October 2018

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

Name:Cancer Diagnosis:

Date of Diagnosis:

 Sections 1–6 applicable to all patients

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

Date of Birth:
End Therapy Date: Section 7
 Section 8
 Section 9

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

CHEMOTHERAPY:  Yes  No
If yes:  Section 10 and applicable guidelines for specific chemotherapy agents below
Mark If
Patient
Received

Chemotherapy Agent

Applicable Guideline Sections

Asparaginase

Section 39

Bleomycin

Section 34

BusulfanSections 11M, 12M, 13F, 14F, 15, 16, 17

Carboplatin: All doses

Sections 11M, 12M, 13F, 14F, 15, 22, 23

Carboplatin: Myeloablative dose (conditioning for HCT)

Section 21

Carmustine (BCNU)

Sections 11M, 12M, 13F, 14F, 15, 16

Chlorambucil

Sections 11M, 12M, 13F, 14F, 15

Cisplatin

Sections 11M, 12M, 13F, 14F, 15, 21, 22, 23

Cyclophosphamide

Sections 11M, 12M, 13F, 14F, 15, 18, 19

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

Section 25

Cytarabine: High dose IV (any single dose ≥1000 mg/m2)

Section 24

Dacarbazine (DTIC)

Sections 11M, 12M, 13F, 14F, 15

Dactinomycin

Section 35

Daunorubicin*
Cumulative dose =mg/m2
Doxorubicin isotoxic dose =mg/m2 = Cumulative dose x 0.5

Section 32, 33

Dexamethasone

Sections 36, 37, 38

Doxorubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 32, 33

Epirubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =mg/m2 = Cumulative dose x 1
Section 32, 33
mg/m2 = Cumulative dose x 0.67

Etoposide (VP16)

Section 42

Idarubicin*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 32, 33
mg/m2 = Cumulative dose x 5

Ifosfamide

Sections 11M, 12M, 13F, 14F, 15, 18, 20

Lomustine (CCNU)

Sections 11M, 12M, 13F, 14F, 15, 16

Mechlorethamine

Sections 11M, 12M, 13F, 14F, 15

Melphalan

Sections 11M, 12M, 13F, 14F, 15

Mercaptopurine (6MP)

Section 26

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

Sections 27, 28, 29

Methotrexate: High dose IV, IO, IT

Sections 30, 31

COG LTFU Guidelines Appendix I – Page 40

Version 5.0 – October 2018

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

Chemotherapy Agent (cont)

Applicable Guideline Sections (cont)Mitoxantrone*
Cumulative dose:
mg/m2
Doxorubicin isotoxic dose =Section 32, 33
mg/m2 = Cumulative dose x 4

Prednisone

Sections 36, 37, 38

Procarbazine

Sections 11M, 12M, 13F, 14F, 15

Temozolomide

Sections 11M, 12M, 13F, 14F, 15

Teniposide (VM26)

Section 42

Thioguanine (6TG)

Section 26

Thiotepa

Sections 11M, 12M, 13F, 14F, 15

Vinblastine

Sections 40, 41

Vincristine

Sections 40, 41*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

Doxorubicin – multiply total dose x 1

Idarubicin – multiply total dose x 5

Mitoxantrone – multiply total dose x 4

Epirubicin – multiply total dose x 0.67

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 43, 44, 95 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 97

Head/Brain

Any

Sections 45, 46, 47, 48, 49, 50, 51, 52, 53M, 54F, 55, 56, 57M,
58F, 60, 61, 63, 64, 66, 67, 68, 69, 70

Head/Brain

Minimum dose specifications apply**

Sections 59, 62, 65

Neck

Any

Sections 63, 64, 66, 67, 68, 69, 70, 71, 78

Neck

Minimum dose specifications apply**

Section 65

AxillaAny

Sections 72F, 73F, 74, 75

Chest

Any

Sections 71, 72F, 73F, 74, 75, 78, 96

Chest

Minimum dose specifications apply**

Section 76

AbdomenAny

Sections 78, 79, 80, 81, 82, 83, 84, 85, 86, 96

Abdomen

Minimum dose specifications apply**

Sections 76, 77

PelvisAny

Sections 83, 84, 85, 87, 88, 91F, 92F, 93F, 94F

TestesAny

Sections 89M, 90M

Spine (whole)

Any

Sections 63, 64, 66, 67, 68, 69, 70, 71, 78, 83, 84, 85, 87, 88,
91F, 92F, 93F, 96

Spine (whole)

Minimum dose specifications apply**

Sections 65, 76

Spine (cervical)

Any

Sections 63, 64, 66, 67, 68, 69, 70, 78

Spine (cervical)

Minimum dose specifications apply**

Section 65

Spine (thoracic)

Any

Sections 71, 78, 96

COG LTFU Guidelines Appendix I – Page 41

Version 5.0 – October 2018

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

Radiation Field* (cont)

Dose (cont)

Applicable Guideline Sections (cont)Spine (thoracic)

Minimum dose specifications apply**

Section 76

Spine (lumbar)

Any

Sections 83, 84, 85, 96

Spine (sacral)

Any

Sections 83, 84, 85, 87, 88, 91F, 92F, 93F

TBI

Any

Sections 43, 44, 45, 46, 47, 52, 57M, 58F, 60, 63, 64, 66, 67,
68, 72F, 73F, 74, 75, 79, 80, 85, 86, 90M, 91F, 92F, 93F, 95

TBI

For cumulative dose calculation
purposes only; these sections are notapplicable to patients who received TBI
alone**

Sections 59, 62, 65, 76, 77*Instructions for Determining Radiation Field
Refer to "Radiation Fields Defined" in COG Long-Term Follow-Up Guidelines Appendix I pages 8-10 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 59, 62, 65, 76, 77) 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 11.
Hematopoietic Cell Transplant:  Yes  No
If yes:  Sections 99M, 100F, 101, 102, 103, 104 and applicable guidelines below
Mark If
Patient
Received

Transplant Type

Chronic GVHD Status

Applicable Guideline Sections

Autologous

N/A

Section 98

Allogeneic

Without history of chronic GVHD

No additional guideline sections

Allogeneic

With history of chronic GVHD

Sections 105, 106, 107, 108, 109, 111, 112F, 113

Allogeneic

With currently active chronic GVHD

Section 110

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

Surgical Procedure

Applicable Guideline Sections

Amputation

Section 114

COG LTFU Guidelines Appendix I – Page 42

Version 5.0 – October 2018

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

Surgical Procedure (cont)

Applicable Guideline Sections (cont)Central venous catheter

Section 115

Cystectomy

Sections 116, 141, 142, 143M, 144M, 145F

Enucleation

Section 117

Hysterectomy

Section 118F

Laparotomy

Section 119

Limb sparing procedure

Section 120

Nephrectomy

Sections 121M, 122F

Neurosurgery – brain (all types)

Sections 123, 124, 125, 126

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

Sections 127, 128

Neurosurgery – spinal cord

Sections 129, 130, 131M, 132F, 133

Oophoropexy

Section 134F

Oophorectomy – unilateral

Section 135F, 136F

Oophorectomy – bilateral

Section 137F

Orchiectomy – unilateral/partial

Sections 138M, 139M

Orchiectomy – bilateral

Section 140M

Pelvic surgery

Sections 141, 142, 143M, 144M, 145F

Splenectomy

Section 146

Thoracic surgery

Sections 147, 148

Thyroidectomy

Section 149

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 150, 151

Systemic MIBG

Sections 152, 153, 154

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

Section 155

Cancer Screening Guidelines
All patients:
 Sections 158, 160, 161, 163
Male patients:
 Sections 162, 164
Female patients:  Sections 156, 157, 159
General Health Screening
All patients:

 Section 165

COG LTFU Guidelines Appendix I – Page 43

Version 5.0 – October 2018

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

Section Number
Comparison
COG LTFU
Guidelines
Version 4.0 vs 5.0
Version 5.0
October 2018

Copyright 2018 © Children’s Oncology GroupAll rights reserved worldwide

Section Number Comparison
COG LTFU Guidelines Version 4.0 vs 5.0
Version
4.0

Version
5.0
Potential Late EffectVersion
4.0

Version
5.0
Potential Late Effect

Any Cancer Experience27

27

Reduced bone mineral density (BMD)28

28

Update in V5:
No known renal late effects related tomethotrexate

1

1

Adverse psychosocial/quality of life effects22

Mental health disorders

3

3

Risky behavior

4

4

Psychosocial disability due to pain

29

29

Hepatic dysfunction

5

5

Fatigue; Sleep problems

30

30

Neurocognitive deficits

66Limitations in healthcare and insurance
access31

31

Clinical leukoencephalopathy

32

32

Acute myeloid leukemia

Blood/Serum Products

33

33

Combined in V5:
Cardiac toxicity

7

7

Chronic hepatitis B

34

8

8

Chronic hepatitis C

35

34

Pulmonary toxicity

99HIV infection

36

35

No known late effects related to dactinomycin

Chemotherapy

37

36

Reduced bone mineral density (BMD)

10

10

Dental abnormalities

38

37

Osteonecrosis (avascular necrosis)

11

12

Impaired spermatogenesis

39

38

Cataracts

1211

Testicular hormonal dysfunction

40

39

No known late effects related to asparaginase

13

13

Separated into 2 sections in V5:
Ovarian hormone deficiencies

41

40

Peripheral sensory or motor neuropathy

42

41

Vasospastic attacks (Raynaud's phenomenon)

14

Separated into 2 sections in V5:
Reduced ovarian follicular pool

43

42

Acute myeloid leukemia

14

15

Acute myeloid leukemia; Myelodysplasia

15

16

Pulmonary fibrosis

16

17

Cataracts

47

17

18

Urinary tract toxicity

18

19

Bladder malignancy

19

20

Renal toxicity

20

21

Ototoxicity

21

22

Peripheral sensory neuropathy

22

23

Renal toxicity

23

24

Neurocognitive deficits

24

N/A

Removed from V5:
Clinical leukoencephalopathy related tocytarabine (high dose IV)

25
26

25
26

No known late effects related to cytarabine(low dose IV, IO, IT, SQ)
Hepatic dysfunction; Sinusoidal obstruction
syndrome (SOS)

COG LTFU Guidelines Appendix I – Page 47

Radiation
44

43

Combined in V5:
Secondary benign or malignant neoplasm
occurring in or near radiation field

46

44

Dermatologic toxicity

48

45

Brain tumor (benign or malignant)49

46

Neurocognitive deficits

50

47

Clinical leukoencephalopathy

51

48

Cerebrovascular complications

52

49

Craniofacial abnormalities

53

50

Chronic sinusitis

54

51

Overweight; Obesity

55

52

Growth hormone deficiency

5653

Precocious puberty (male)

57

54

Precocious puberty (female)

58

55

Combined in V5:Hyperprolactinemia

45

59

Version 5.0 – October 2018

Section Number Comparison
COG LTFU Guidelines Version 4.0 vs 5.0 (cont)Version
4.0

Version
5.0
Potential Late EffectVersion
4.0

60

56

Central hypothyroidism

92

61

57

Gonadotropin deficiency (male)

93

62

58

Gonadotropin deficiency (female)

63

59

64

Version
5.0
Potential Late Effect87

Combined in V5:
Urinary tract toxicity

94

88

Bladder malignancy

Central adrenal insufficiency

95

93

Uterine vascular insufficiency

60

Cataracts

96

91

65

61

Ocular toxicity

Separated into 2 sections in V5:
Ovarian hormone deficiencies

66

62

Combined in V5:
Ototoxicity

92

Separated into 2 sections in V5:
Reduced ovarian follicular pool

68

63

Xerostomia; Salivary gland dysfunction

97

94

Vaginal fibrosis/stenosis

69

64

Dental abnormalities; Temporomandibular
joint dysfunction

98

90

Impaired spermatogenesis

99

89

Testicular hormonal dysfunction70

65

Osteoradionecrosis of the jaw

100

95

Musculoskeletal growth problems

71

66

Thyroid nodules

101

96

Scoliosis/Kyphosis

72

67

Thyroid cancer

102

97

Radiation-induced fracture

73

68

Hypothyroidism

74

69

Hyperthyroidism

75

70

Carotid artery disease76

71

Subclavian artery disease

77

72

Breast cancer

78

73

Breast tissue hypoplasia

79

74

Pulmonary toxicity

N/A

75

New in V5:Lung cancer

80

76

Combined in V5:
Cardiac toxicity

67

81

Hematopoietic Cell Transplant (HCT)103

98

Acute myeloid leukemia; Myelodysplasia

104

99

Solid tumors (male)

105

100

Solid tumors (female)

106

N/A

Removed from V5:
Lymphoma related to HCT

107

101

Hepatic toxicity

108

102

Osteonecrosis (avascular necrosis)

109

103

Reduced bone mineral density (BMD)

110

104

Renal toxicity

82

77

Functional asplenia

111

105

Dermatologic toxicity

83

78

Esophageal stricture

112

106

Xerophthalmia (keratoconjunctivitis sicca)

84

79

Impaired glucose metabolism/diabetes
mellitus

113

107

Oral toxicity

114

108

Pulmonary toxicity

85

80

Dyslipidemia

115

109

Immunologic complications

86

81

Hepatic toxicity

116

110

Functional asplenia

87

82

Cholelithiasis

117

111

Esophageal stricture88

83

Bowel obstruction

118

112

Vulvar scarring; Vaginal fibrosis/stenosis

89

84

Chronic enterocolitis; Fistula; Strictures

119

113

Joint contractures

90

85

Colorectal cancer

91

86

Renal toxicity

COG LTFU Guidelines Appendix I – Page 48

Surgery
120

114

Amputation-related complications

Version 5.0 – October 2018

Section Number Comparison
COG LTFU Guidelines Version 4.0 vs 5.0 (cont)Version
4.0
121

Version
5.0
Potential Late Effect115

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

Version
4.0

Version
5.0
Potential Late Effect

145

141

Urinary incontinence; Urinary tract obstruction

146

142

Fecal incontinence

147

143

Separated into 2 sections in V5:
Psychosexual dysfunction (male)

144

Separated into 2 sections in V5:
Sexual dysfunction (anatomic); Infertility (male)

122

116

Cystectomy-related complications

123

117

Impaired cosmesis; Poor prosthetic fit; Orbital
hypoplasia

124

118

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

148

145

Sexual dysfunction (female)

149

146

Asplenia

125

119

Adhesions; Bowel obstruction

150

147

Pulmonary dysfunction

126

120

Complications related to limb sparing
procedure

151

148

Scoliosis/Kyphosis

127

121

Hydrocele; Renal toxicity (male)

152

149

Hypothyroidism

128

122

Renal toxicity (female)

129

123

Neurocognitive deficits

130

124

Motor and/or sensory deficits

131

125

Seizures132

126

Hydrocephalus; Shunt malfunction

133

127

Overweight; Obesity

134

128

Diabetes insipidus

135

129

Neurogenic bladder; Urinary incontinence

136

130

Neurogenic bowel; Fecal incontinence

137

131

Psychosexual dysfunction (male)

138

132

Psychosexual dysfunction (female)

157

156

Breast cancer (female)

139

133

Scoliosis/Kyphosis

158

157

Cervical cancer (female)

140

134

Oophoropexy-related complication

159

158

Colorectal cancer

141

135

Separated into 2 sections in V5:
Ovarian hormone deficiencies

160

159

Endometrial cancer (female)

161

160

Lung cancer

136

Separated into 2 sections in V5:
Reduced ovarian follicular pool

162

161

Oral cancer

163

162

Prostate cancer (male)

142

137

Ovarian hormone deficiencies; Loss of ovarianfollicular pool

164

163

Skin cancer

143

138

Separated into 2 sections in V5:
Testicular hormonal dysfunction

165

164

Testicular cancer (male)

139

Separated into 2 sections in V5:
Impaired spermatogenesis

140

Testosterone deficiency; Azoospermia

144

COG LTFU Guidelines Appendix I – Page 49

Other Therapeutic Models
153

150

Lacrimal duct atrophy

154

151

Hypothyroidism

155

152

Hypothyroidism

N/A

153

New to V5:
Thyroid nodules

N/A

154

New to V5:
Thyroid cancer

156

155

Insufficient information currently available
regarding late effects of biological agents
Cancer Screening Guidelines

General Health Screening
166

165

General health screening

Version 5.0 – October 2018