Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 2.0 – March 2006

Appendix I
Materials forClinical Applicationof LTFU Guidelines

Copyright 2006 © Children’s Oncology GroupAll rights reserved worldwide

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 2.0 – March 2006

Reference Materials

Copyright 2006 © Children’s Oncology GroupAll rights reserved worldwideAbbreviations
Abbreviation
AAP-CIDP
ABR
AFP
ACS
AHA
ALT
AST
ATM
AVN
BAER
BCNU
BMD
BMI
BRCA1
BRCA2
BUN
Ca
CBC
CCG
CCNU
CD-4
CDC
cGVHD
Cl
CNS
CO2
COG
CSF
CT
CXR
DES
DEXA
DLCO
DOE
EBMT
ECHO
EKG
EIA
FAP
FNA
FSH
GH
GVHD
Gy
HBcAb
HBsAg
HCT
HCV
HDL
HIB
HIV

Definition
American Academy of Pediatrics Committee on Infectious Disease Prevention
Brainstem auditory evoked responses
Alpha fetoprotein
American Cancer Society
American Heart Association
Alanine aminotransferase
Aspartate aminotransferase
Ataxia telangiectasia cancer susceptibility gene located on chromosome 11
Avascular necrosis
Brainstem auditory evoked responses
Carmustine
Bone mineral density
Body mass index
Breast cancer, early onset gene (cancer susceptibility gene located on chromosome 17)
Breast cancer 2, early onset gene (cancer susceptibility gene located on chromosome 13)
Blood urea nitrogen
Calcium
Complete blood countChildren’s Cancer Group
Lomustine
Cluster of differentiation antigen associated with helper T lymphocyte
Centers for Disease Control
Chronic graft versus host disease
Chloride
Central nervous system
Carbon dioxide
Children’s Oncology Group
Cerebral spinal fluid
Computed tomography
Chest radiograph
Diethylstilbestrol
Dual energy x-ray absorptiometry
Diffusion capacity of carbon monoxide
Dyspnea on exertion
European Group for Blood and Marrow Transplant
Echocardiogram
Electrocardiogram
Enzyme immunoassay
Familial adenomatous polyposis
Fine needle aspirate
Follicle stimulating hormone
Growth hormone
Graft versus host disease
Gray
Hepatitis B core antibody
Hepatitis B surface antigen
Hematopoietic cell transplant
Hepatitis C virus
High-density lipoproteins
Haemophilus influenza B
Human immunodeficiency virus

Abbreviations
Page 1

Abbreviations (cont)Abbreviation
HNPCC
HPF
HPV
HRT
Hz
IBD
K
I-131
IQ
IT
IV
IVIG
KUB
LH
MIBG
Mg
MOPP
MRI
MUGA
Na
NCEP
NCHS
NF1
NSAIDs
OAE
OCP
PAP
PCR
PFTs
p53
PO
PO4
PRN
PSA
QCT
QTc
RB1
RBC
RDA
RUQ
SCUBA
SD
SOB
T4
TBI
TPN
TSH
U/A
USPSTF
VOD
VZIGDefinition
Hereditary nonpolyposis colorectal cancer
High power field
Human papilloma virus
Hormonal replacement therapy
Hertz
Inflammatory bowel disease
Potassium
Iodine 131 radioisotope
Intelligence quotient
Intrathecal
Intravenous
Intravenous immunoglobulin
Kidneys, ureters, bladder radiograph
Luteinizing hormone
Iodine-131-meta-iodobenzylguanidine
Magnesium
Mechlorethamine, Oncovin, Procarbazine, Prednisone
Magnetic resonance imaging
Multiple Gated Acquisition scan
SodiumNational Cholesterol Education Program
National Center for Health Statistics
Neurofibromin 1 (neurofibromatosis) cancer susceptibility gene located on chromosome 17
Non-steroidal anti-inflammatory drugs
Otoacustic emissions
Oral contraceptive pills
Papanicoulau
Polymerase chain reaction
Pulmonary function tests
Cancer susceptibility gene located on chromosome 17 associated with familial cancers
By mouth
Phosphate
As needed
Prostate specific antigen
Quantitative computed tomography
Corrected QT interval
Retinoblastoma gene – cancer susceptibility gene located on chromosome 13
Red blood cell
Recommended daily allowance
Right upper quadrant
Self-contained underwater breathing apparatus
Standard deviation
Shortness of breath
Thyroxine
Total body irradiation
Total parenteral nutrition
Thyroid stimulating hormone
Urinalysis
United States Preventive Services Task Force
Veno-occlusive disease
Varicella zoster immunoglobulin

Abbreviations
Page 2

Chemotherapy Agents
Generic Name
Asparaginase

Additional Name(s)Elspar®

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

Blenoxane®

Anti-tumor antibiotic

BusulfanBusulfex®

Alkylating agent

Busulphan
Myleran®
Carboplatin

CBDCA

Heavy metal

Paraplatin®
Carmustine

BCNU

Alkylating agent

BiCNU®
Chlorambucil

Leukeran®

Alkylating agent

Cisplatin

CDDP

Heavy metal

Cisplatinum
Platinol®
Cyclophosphamide

CPM

Alkylating agent

Cytoxan®
Neosar®
Procytox®
Cytarabine

Ara-C

Antimetabolite

Cytosar®
Cytosar-U®
Cytosine arabinoside
Dacarbazine

DTIC

Non-classical alkylator

DTIC-Dome®
Dactinomycin

Actinomycin-D

Anti-tumor antibiotic

Cosmegen®
Daunorubicin

Cerubidine®

Anthracycline antibiotic

Daunomycin
DaunoXome®
Dexamethasone

Decadron®

Corticosteroid

Doxorubicin

Adriamycin®

Anthracycline antibiotic

Doxil®
Rubex®
Epirubicin

Ellence®

Anthracycline antibiotic

Pharmorubicin PFS®

Chemotherapy Agents
Page 1

Chemotherapy Agents (cont)
Generic Name
Etoposide

Additional Name(s)VePesid®

Classification
Epipodophyllotoxin

VP-16
Idarubicin

Idamycin®

Anthracycline antibiotic

Ifosfamide

Ifex®

Alkylating agent

Lomustine

CeeNU®

Alkylating agent

CCNU
Mechlorethamine

Mustargen®

Alkylating agent

Nitrogen Mustard
Melphalan

Alkeran®

Alkylating agent

Mercaptopurine

6-Mercaptopurine

Antimetabolite

6-MP
Purinethol®
Methotextrate

Amethopterin

Antimetabolite

Folex®
Mexate®
Trexall®
Mitoxantrone

Novantrone®

Anthracycline antibiotic

Prednisone

Deltasone®

Corticosteroid

Methylprednisolone
Prednisolone
Procarbazine

Matulane®

Alkylating agent

Natulan®
Temozolomide

Temodal®

Non-classical alkylator

Temodar®
Teniposide

VM-26

Epipodophyllotoxin

Vumon®
Thioguanine

Lanvis®

Antimetabolite

Tabloid®
6-Thioguanine
6-TG
Thiotepa

Thioplex®

Alkylating agent

Vinblastine

VBL

Plant alkaloid

Velban®
Velbe®
Vincristine

Oncovin®

Plant alkaloid

VCR
Vincasar®
Vincrex®

Chemotherapy Agents
Page 2

Radiation Fields DefinedTermDefinition

CranialWhole brain

Waldeyer’s Ring

Oropharyngeal + nasopharyngeal (tonsils and adenoids)

Spine – cervical

Including some or all of cervical spine (C1-C7)

Spine – thoracic

Including some or all of thoracic spine (T1-T12)

Spine – lumbar

Including some or all of lumbar spine (L1-L5)

Spine – sacral

Including sacrum (S1-S5)

MantleBilateral: cervical (neck), supraclavicular, mediastinal, hilar, axillary

Extended mantle

Mantle + paraaortic

Mini-mantle

Cervical (neck), supraclavicular, axillary (excludes mediastinal and lung)Mediastinal

Includes mediastinum plus bilateral hilar

Whole abdomen

Upper abdomen and pelvis

Upper abdomen

Top of diaphragm to iliac crest (bilateral).
"Any upper abdominal field" refers to any radiation field located between
the top of the diaphragm and the iliac crest, including the following:
hepatic, hemiabdomen/flank, upper quadrant, renal bed, spleen (partial,
entire), splenic pedicle, inverted Y, and paraaortic.

Flank/hemiabdomen

Top of diaphragm to iliac crest (unilateral; medial border alongcontralateral vertebral bodies).
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 the patient’s risk for late sequelae.

Renal

Renal bedParaaortic

Para-aortic lymph nodes (generally from T10 to L4 cephalad-caudad, andthe transverse processes laterally) +/- spleen/splenic pedicle

PelvicIliac crest to 3 cm below ischium. Includes iliac, inguinal, + femoral lymph
nodes, bladder + prostate (male) or uterus, vagina, ovaries [if not
surgically relocated] (female).

Inverted Y

Paraaortic + pelvic + spleen/splenic pedicle

Subtotal lymphoid(STLI)

Mantle + paraaortic + splenic

Total lymphoid (TLI)

Mantle + Inverted Y + spleen/splenic pedicle

Radiation Fields
DefinedLong-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 2.0 – March 2006

Summary ofCancer Treatment

Copyright 2006 © Children’s Oncology GroupAll rights reserved worldwide

Summary of Cancer Treatment Introduction
Importance of a Comprehensive Cancer Treatment Summary
The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors ofChildhood, Adolescent, and Young Adult Cancers are based on therapeutic exposures
received during cancer treatment. Availability of a comprehensive treatment summary,
including all therapeutic agents received by the survivor, is presumed. Patients who do
not have a comprehensive treatment summary should be instructed to obtain one fromthe institution(s) where they received their treatment. Ideally, the comprehensive
treatment summary should include the following information:
S Demographics (name, sex, date of birth, contact information)
S Diagnosis, including site/stage, date, and relapse(s) if any
S Pertinent secondary diagnoses (e.g., second malignancy, Down syndrome)
S Treatment protocol information, if applicable
S All chemotherapy agents received during treatment (including route ofadministration for all agents, cumulative doses for alkylators, bleomycin, andanthracyclines, and designation of “high dose” versus “standard dose” formethotrexate and cytarabine). Cumulative doses for all other agents should be
provided if available. Note: “High dose” methotrexate/cytarabine is defined as
any single dose >1000 mg/m2. “Standard dose” methotrexate/cytarabine isdefined as all single doses <1000 mg/m2. See section 28 of Guidelines foranthracycline 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).
S Radiation therapy summary, including field(s), laterality (if applicable), start/stop
dates, number of fractions, dose per fraction, boost dose/location (if applicable),
total dose (in Gy), and radiation type. Note: To convert cGy or rads to Gy, divide
dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)
S Hematopoietic cell transplant(s), including type(s), date(s), conditioning
regimen(s), and GVHD prophylaxis and/or treatment
S Surgical procedures, including date, site, and laterality if applicable
S Other therapeutic modalities (e.g., biologicals, systemic radiation)
S Significant complications/late effects with dates of onset/resolution
S Adverse drug reactions/allergies
Minimum Information Necessary to Generate Patient-Specific Guidelines:
In order to generate accurate exposure-based follow-up recommendations from theseguidelines, the following information regarding the survivor’s diagnosis and treatment isrequired, at minimum:
S

Survivor’s sex

SSurvivor’s date of birth

S

Date of cancer diagnosis

S

Date cancer therapy was completed

Introduction
Page 1

Summary of Cancer Treatment Introduction (cont)S

S

Names of all chemotherapy agents received. Note: For a list of chemotherapy
agents addressed by these guidelines, see Chemotherapy portion of the Index(sections 6-37). 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), and age at firstanthracycline dose (if unknown, age at first anthracycline dose is presumed to be
age at diagnosis). Note: For anthracycline isotoxic dose-equivalent conversion,see Section 28 of Guidelines. For doses in mg/kg, multiply by 30 to obtainequivalent dosing in mg/m2 (example: 2 mg/kg = 60 mg/m2).

S

For carboplatin: Whether any dose was myeloablative (i.e., given as conditioningfor HCT).

S

For cytarabine and methotrexate:S

Route of administration (i.e., IV, IM, SQ, PO, IT, IO)

S

S

S

If IV: Designation of “high dose” (any single dose >1000 mg/m2) versus“standard dose” (all single doses <1000 mg/m2)
All radiation field(s) and total radiation dose (in Gy) to each field. For chest,
thoracic spine, and upper abdominal radiation, include age at first dose; if
unknown, age at first dose is presumed to be age at diagnosis. Note: Total
radiation dose to each field should include boost dose, if given. To convert cGyor rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy). For
list of radiation fields addressed by these guidelines, see Radiation portion ofIndex (Sections 38-91). For clarification of anatomical areas included in common
radiation fields, see Radiation Fields Defined in Appendix I.
Whether or not the survivor underwent a hematopoietic cell transplant (HCT),
and if so, whether or not the survivor developed chronic graft-versus-hostdisease (cGVHD).

S

Names of all relevant surgical procedures. Note: For list of surgical procedures
addressed by these guidelines, see “Surgery” portion of Index (Sections 107132).

S

Names of all other therapeutic modalities. Note: For list of other therapeuticmodalities addressed by these guidelines, see “Other Therapeutic Modalities”
portion of Index (Sections 133-36).

Templates for Summary of Cancer Treatment
Two templates for summarizing cancer treatment are included in Appendix I (and alsoavailable in electronic format at www.survivorshipguidelines.org). These templates wereoriginally developed in 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, then further 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, andmeets the minimum data requirements for initial use of the “Passport for Care” webbased guideline interface. However, the COG Late Effects Committee recognizes thatas new evidence becomes available and these guidelines are updated, additional details

Introduction
Page 2

Summary of Cancer Treatment Introduction (cont)regarding the childhood cancer survivor’s therapeutic exposures may be required inorder to generate comprehensive recommendations. Therefore, we strongly advise thata 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 notcurrently addressed by these guidelines.
In addition to the treatment summary templates, a “key” for completing thecomprehensive version of the treatment summary is also included in Appendix I. This“key” correlates to the drop-down menus that will be available in the web-based“Passport for Care” guideline interface.

Introduction
Page 3

SUMMARY OF CANCER TREATMENT(Abbreviated)
DEMOGRAPHICS
Name:

Sex:

Date of Birth:

CANCER DIAGNOSIS
Diagnosis:

Date of Diagnosis:

CHEMOTHERAPY:

Yes

No

Drug Name†

Date Therapy Completed:

If yes, complete chart below
Additional Information†

2

Anthracyclines: Include cumulative dose in mg/m and age at first dose (see section 28 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);
2
2
IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose >1000 mg/m ) or “standard dose” (all single doses <1000 mg/m )Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

RADIATION

YesNo

If yes, complete chart below

Site/Field*

Total Dose** (Gy)**** For chest, thoracic spine, and upper abdominal radiation, include age at first dose ** Total dose to each field should include boost dose, if given*** 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, answer question below

Yes

Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)?

SURGERY

Yes

No

Procedure

If yes, complete chart below
Site (if applicable)

OTHER THERAPEUTIC MODALITIES

Yes

No

Laterality (if applicable)

If yes, answer questions below

Did this patient receive radioiodine therapy (I-131 thyroid ablation)?

Yes

No

Did this patient receive systemic MIBG (in therapeutic doses)?

Yes

No

Did this patient receive bioimmunotherapy?

Yes

No

Summary prepared by:No

Date prepared:

Summary Form - AbbreviatedSUMMARY OF CANCER TREATMENT(Comprehensive)
DEMOGRAPHICS
Name: (last, first, middle)

Sex: (M/F)

Date of Birth:

COG Reg #:Address: (number, street, city, state/province, postal code, country)
Phone:

SS#

Race/Ethnicity: (see list #1)

Alternate contact:

Relationship:

Phone:CANCER DIAGNOSIS
Diagnosis: (see list #2)
Date of Diagnosis:

Age at Diagnosis:

Date Therapy Completed:

Sites involved/stage/diagnostic details:

Laterality: (Right/Left/NA)

Hereditary/congenital history: (see list #3)
Pertinent past medical history:
Treatment Center:

Medical Record #:MD/APN Contact Information:

RELAPSE(S)
Date:

Yes

Site(s):No If yes, provide information below
Laterality: (Right/Left/NA)
Date Therapy Completed:

SUBSEQUENT MALIGNANT NEOPLASM(S)
Date:Stage/Site(s):No

If yes, provide information below

Date Therapy Completed:

CANCER TREATMENT SUMMARYPROTOCOL(S)
Yes
No
Acronym/Number

Title/Description

CHEMOTHERAPY

Yes

No

Drug Name(see list # 5)†

Yes

Type: (see list #4)

If yes, provide information below
Initiated

If yes, complete chart below
Route(see list #6)

Completed

On-Study

Additional Information†(see list #7)

2

Anthracyclines: Include cumulative dose in mg/m and age at first dose (see section 28 of Guidelines for isotoxic dose conversion);
2
Carboplatin: Indicate if dose was myeloablative; IV Methotrexate and Cytarabine: Indicate if “high dose” (any single dose >1000 mg/m )2
or “standard dose” (all single doses <1000 mg/m );Note: Cumulative doses, if known, should be recorded for all agents, particularly for alkylators and bleomycin.

Summary Form - Comprehensive
Page 1(
RADIATION
Site/Field

Yes
Laterality

No
Start
Date

)

If yes, complete chart below

Stop
Date

Fractions

Dose perFraction(Gy)*

InitialDose(Gy)*

Boost Site(see list #8)

Boost
Dose
(Gy)*

Total Dose(including
boost)(Gy)*(see list #9)

Radiation oncologist:Type(see list #10)

Institution:*Note: To convert cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy)

HEMATOPOIETIC CELL TRANSPLANT
Type(see list #11)

Yes

Tandem?

Yes

SourceNo If yes, complete chart below
Conditioning Regimen
Institution/Treating MD

Date of
Infusion(see list #12)(see list #13)

No

GVHD prophylaxis/treatment (For transplant patients only)

Yes

Type

No

First DoseIf yes, complete chart below
Last Dose(see list #14)

Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)?

SURGERY

Yes

Date

No
ProcedureYesNo

If yes, complete chart below
Site (if applicable)
Laterality (if applicable)

Surgeon/Institution(see list #15)

OTHER THERAPEUTIC MODALITIES

Yes

No

TherapyRoute(see list # 16)(see list #6)

COMPLICATIONS/LATE EFFECTS
Problem

Yes

No

Date onset(see list #17)

Adverse Drug Reactions/Allergies
Drug

Yes

Additional Information/Comments

Yes

Summary prepared by: (name/title/institution)
Summary updated by: (name/title/institution)(see list #7)

If yes, complete chart below
Date resolved
Status(Active/Resolved)(Active/Resolved)(Active/Resolved)(Active/Resolved)(Active/Resolved)

No

ReactionNo

If yes, complete chart below
Cumulative Dose (if known)

If yes, complete chart below
Date
Status(Active/Resolved)(Active/Resolved)
If yes, provide information below

Date prepared:
Date updated:

Summary Form - Comprehensive
Page 2

KEY FOR COMPLETING SUMMARY OF CANCER TREATMENT(Comprehensive Version)#1: Race/Ethnicity
Asian
Black
Caucasian (non-Hispanic)
Hispanic
Native American/Alaskan Native
Native Hawaiian/Pacific IslanderMulti-racial/multi-ethnic
Other (specify):#2: Cancer Diagnosis
Central Nervous System Tumor
Astrocytoma
Cerebellar astrocytoma
Supratentorial astrocytoma
Brainstem glioma
Choroid plexus neoplasm
Craniopharyngioma
Ependymoma
Germ cell tumor, intracranial, specify type:__________
Optic glioma
Pineal tumor
PNET
Cerebellar (medulloblastoma)
Supratentorial PNET
Spinal cord tumor, intramedullary
CNS tumor, other, specify:___________________
Endocrine tumor
Adrenal tumor (non-neuroblastoma)
Thyroid tumor
Parathyroid tumor
Gastroenteropancreatic tumor
Multiple endocrine neoplasia syndrome
Endocrine tumor, other, specify:___________________
Germ cell tumor (extracranial)
Seminoma
Germinoma
Dysgerminoma
Non-seminomas
Yolk sac tumor
Embryonal carcinoma
Choriocarcinoma
Teratoma
MatureImmatureWith malignant transformation
Germ cell tumor, other, specify:_____________

Summary Form - KeyPage 1#2: Cancer Diagnosis (continued)
Leukemia
Acute lymphoblastic leukemia
Acute myeloid leukemia
Chronic myeloid leukemia
Myelodysplastic syndrome
Myeloproliferative disorder
Leukemia, other, specify:_________
Liver tumor
Hepatoblastoma
Hepatocellular carcinoma
Liver tumor, other, specify: _________
Lymphoma
Hodgkin lymphoma
Non-Hodgkin lymphoma
Lymphoblastic lymphoma
Burkitt’s lymphoma
Large cell lymphoma
Anaplastic large cell lymphoma
Diffuse large B-cell lymphoma
Lymphoma, other, specify:________
Nasopharyngeal carcinoma
Neuroblastoma
Ganglioneuroblastoma
Renal tumor
Wilms tumor
Clear cell sarcoma
Renal cell carcinoma
Renal tumor, other:Retinoblastoma
SarcomaEwing’s sarcoma/peripheral PNET
Osteosarcoma
Rhabdomyosarcoma
Soft tissue sarcoma (nonrhabdomyosarcomatous)
Alveolar soft part sarcoma
Fibrosarcoma
Leiomyosarcoma
Liposarcoma
Malignant fibrous histiocytoma
Malignant peripheral nerve sheath tumor
Neurofibrosarcoma
Synovial sarcoma
Undifferentiated sarcoma
Sarcoma, other, specify: ____________
Skin cancer
Basal cell carcinoma
Malignant melanoma
Squamous cell carcinoma
Skin cancer, other, specify:____________
Malignancy, other, specify:
Langerhans cell histiocytosis
Diagnosis, other, specify:
Unknown

Summary Form - KeyPage 2 of 14
Page 2

#3: Hereditary/Congenital History
Congenital heart disease
Congenital disease, other, specify:
Hemihypertrophy
Neurofibromatosis
Type I
Type II
Down syndrome
Syndrome, other, specify:
Hereditary condition, other, specify:
None
Unknown#4: Subsequent Malignancy Diagnosis
Leukemia
Acute lymphoblastic leukemia
Acute myeloid leukemia
Chronic myeloid leukemia
Myelodysplastic syndrome
Myeloproliferative disorder
Leukemia, other, specify:
Lymphoma
Hodgkin lymphoma
Non-Hodgkin lymphoma
Lymphoblastic lymphoma
Burkitt’s lymphoma
Large cell lymphoma
Post-transplant lymphoproliferative disorder (PTLD)
Lymphoma, other, specify:
SarcomaEwing’s sarcoma/peripheral PNET
Osteosarcoma
Rhabdomyosarcoma
Soft tissue sarcoma (nonrhabdomyosarcomatous)
Undifferentiated sarcoma
Other sarcoma, specify:
Thyroid cancer
Skin cancer
Basal cell carcinoma
Malignant melanoma
Squamous cell carcinoma
Breast cancer
Central nervous system tumor
Malignant, specify type and location:
Meningioma, specify location:
Other CNS tumor, specify type:
Gastrointestinal cancer
Esophageal cancer
Stomach cancer
Colorectal cancer
Hepatocellular carcinoma
Pancreatic cancer
Other GI cancer, specify:

Summary Form - KeyPage 3#4: Subsequent Malignancy Diagnosis (continued)
Lung cancer
Bladder cancer
Renal cancer
Renal cell carcinoma
Clear cell sarcoma
Other renal cancer, specify:_________
Cervical cancer
Peripheral nerve sheath tumor/Schwannoma
Malignancy, other, specify:
None
Unknown#5: Chemotherapy
Asparaginase
Bleomycin
Busulfan
Carboplatin
Myeloablative dose?
Yes
No
Carmustine (BCNU)
Chlorambucil
Cisplatin
Cladribine
Clofarabine
Cyclophosphamide
Cytarabine
If IV: Any single dose >1000 mg/m2?
Dacarbazine (DTIC)
Dactinomycin
Daunorubicin
Dexamethasone
Docetaxel
Doxorubicin
Epirubicin
Etoposide (VP-16)
Fludarabine
Fluorouracil
Gemcitabine
Hydrocortisone
Hydroxyurea
Idarubicin
Ifosfamide
Imatinib Mesylate
Irinotecan
Lomustine (CCNU)
Mechlorethamine
Melphalan
Mercaptopurine
Methotrexate
If IV: Any single dose >1000 mg/m2?
Mitoxantrone
Oxaliplatin
Paclitaxel
Prednisone

Yes

No

Yes

No

Summary Form - KeyPage 4#5: Chemotherapy (continued)
Procarbazine
Temozolomide
Teniposide (VM-26)
Thioguanine (6-TG)
Thiotepa
Topotecan
Trimetrexate
Vinorelbine
Vinblastine
Vincristine
Other, specify:
None
Unknown#6: Route
PO
IM
IV
SQ
IT
IO
Other, specify:
Unknown#7: Cumulative Dose (Note: this is a required field for anthracyclines and optional but suggested for all others)
mg/m2
units/m2
mg/kg (Note: computer will multiply mg by 30 and display as mg/m2)
Not available
Not applicable
Other, specify:
Unknown#8: Radiation Site/Field
Head/brain
CranialCraniospinal (Note: if selected, computer will prompt user to enter data for both cranial and spinal fields]
Orbital/eye, specify: Right, left, bilateral
Ear/infratemporal, specify: Right, left, bilateral
Nasopharyngeal
Oropharyngeal
Waldeyer’s Ring
Other head/brain radiation, specify:________
Neck
Cervical (neck), specify: Right, left, bilateral
Supraclavicular, specify: Right, left, bilateral
Spine
Spine - cervical
Spine - thoracic
Spine - lumbar
Spine - sacral

Page
5 of 14
Summary Form
- Key
Page 5

#8: Radiation Site/Field (continued)
Chest (thorax)
Lung (whole), specify: Right, left, bilateral
MantleMini-Mantle
Extended Mantle
Mediastinal
Hilar
Axilla, specify: Right, left, bilateral
Chest, other, specify:_________
Abdomen
Whole abdomen
Upper abdomen, specify field(s) if applicable:
Hepatic
Hemiabdomen/flank, specify: Right, left
Upper quadrant, specify: Right, left, bilateral
Renal bed, specify: Right, left, bilateral
Spleen, specify: partial, entire
Splenic pedicle
Inverted Y
Paraaortic
PelvisPelvicVaginaProstate
Bladder
Iliac
Inguinal
FemoralInverted Y
Testicular, specify: Right, left, bilateral
Skeletal
Extremity
Upper, specify: Right, left, bilateral; specify: proximal, distal, entire
Lower, specify: Right, left, bilateral; specify: proximal, distal, entire
Bone, specify:
Other, specify:
Total Body Irradiation (TBI)
Total Lymphoid Irradiation (TLI)
Subtotal Lymphoid Irradiation (STLI)Other, specify:
Add comment:
None
Unknown#9: Radiation Boost
Tumor bed, specify location:
Other location, specify:
None
Unknown
Add comment:

Summary Form - KeyPage 6

#10: Radiation Type
Brachytherapy
Conformal
External beam (conventional)
IMRT
Stereotactic
Other, specify:
None
Unknown#11: Hematopoietic Cell Transplant - Type
Autologous
Matched related
Mismatched related
Haploidentical related
Syngeneic
Matched unrelated
Other, specify:
None
Unknown#12: Hematopoietic Cell Transplant - Source
Bone marrow
Peripheral blood stem cells
Cord blood
Other, specify:
None
Unknown#13: Hematopoietic Cell Transplant - Conditioning Regimen
ATG
Busulfan
Carmustine (BCNU)
Cyclophosphamide
Etoposide
Fludarabine
MelphalanThiotepa
TBI
Other, specify:
None
Unknown#14: GVHD Prophylaxis/Treatment
ATG
Cyclosporine
Methotrexate
MMF (mycophenolate mofetil)
Prednisone
PUVA
Sirolimus
Tacrolimus
Other, specify:
None
Unknown

Summary Form - KeyPage 7

#15: Surgery
Amputation, specify: Right, left, bilateral; specify site:
Central venous catheter
Cystectomy
Enucleation specify: Right, left, bilateral
Laparotomy
Limb sparing procedure, specify: Right, left, bilateral; specify site:
Nephrectomy, specify: Right, left, bilateral
Neurosurgery - brain
Craniotomy
Ventriculoperitoneal shunt
Other, specify:
Neurosurgery - spinal
Laminectomy
Other, specify:
Orchiectomy, specify: Right, left, bilateral
Pelvic surgery
Hysterectomy
Oophoropexy
Oophorectomy, specify: Right, left, bilateral
Pelvic surgery, other, specify:
Pulmonary lobectomy, specify site:
Pulmonary wedge resection, specify site:
Pulmonary metastasectomy, specify site:
Splenectomy
Thyroidectomy
Other, specify:
None
Unknown#16: Other Therapeutic Modalities
Systemic Radiation
Radioiodine therapy (I-131 thyroid ablation)
Systemic MIBG (in therapeutic doses)
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:
Other, specify:
Other therapeutic modality, specify:
None
Unknown

Summary Form - KeyPage 8

#17: Complications/Late Effects (by system)
Psychosocial
Behavioral problems/behavioral change
Educational problems
Fatigue
Limitations in healthcare access and/or insurance
Psychosocial disability due to pain
Anxiety
Depression
Post-traumatic stress
Psychosocial disability due to pain
Social withdrawal
Risky behaviors
Tobacco use
Alcohol abuse
Substance abuse
Other, specify:
Psychosocial maladjustment
Impaired quality of life
Psychosocial complication, other, specify:
OcularCataract
Enophthalmos
Orbital hypoplasia
Glaucoma
Keratitis
Xerophthalmia (keratoconjunctivitis sicca)
Lacrimal duct atrophy
Optic chiasm neuropathy
Retinopathy
Telangiectasia
Maculopathy
Papillopathy
Chronic painful eye
Visual impairment (uncorrectable)
Ocular nerve palsy
Gaze paresis
Nystagmus
Papilledema
Optic atrophy
Ocular complication, other, specify:
Auditory
Eustachian tube dysfunction
Hearing loss (requires hearing aids?
Yes
No)
Sensorineural hearing loss
Conductive hearing loss
Otosclerosis
Tinnitus
Tympanosclerosis
VertigoAuditory complication, other, specify:
DentalDental abnormalities
Enamel dysplasia
Root thinning/shortening

Summary Form - KeyPage 9#17: Complications/Late Effects (by system, continued)
Tooth/root agenesis
Microdontia
Periodontal disease
Tooth decay
Malocclusion
Xerostomia (salivary gland dysfunction)
Osteoradionecrosis
Temporomandibular joint dysfunction
Dental complication, other, specify:
Cardiovascular
Arrhythmia
Atherosclerotic heart disease
Cardiomyopathy
Congestive heart failure
Myocardial infarction
Pericardial fibrosis
Pericarditis
Subclinical left ventricular dysfunction
Valvular disease
Carotid artery disease
Subclavian artery disease
Thrombosis/vascular insufficiency (related to central line)
Vasospastic attacks (Raynaud’s phenomenon)
Cardiovascular complication, other, specify:
PulmonaryBronchiolitis obliteransInterstitial pneumonitis
Pulmonary fibrosis
Pulmonary dysfunction
Acute respiratory distress syndrome (ARDS)
Obstructive lung disease
Restrictive lung disease
Chronic bronchitis
Bronchiectasis
Pulmonary complication, other, specify:
Gastrointestinal/Hepatic
Abdominal adhesions
Bowel obstruction
Bowel strictures
Fecal incontinence
Cholelithiasis
Cholecystitis
Chronic enterocolitis
Esophageal stricture
FistulaMalabsorption
Nutritional deficiency
Vitamin B12, folate or carotene deficiency
Cirrhosis
Hepatic fibrosis
Hepatic dysfunction
Chronic hepatitis (non-infectious)
Iron overload
Venocclusive disease (VOD) of the liver
Gastrointestinal/hepatic complication, other, specify:

Summary Form - KeyPage 10

#17: Complications/Late Effects (by system, continued)
Endocrine/Metabolic
Hypothyroidism
Primary hypothyroidism (thyroid gland failure)
Secondary (central) hypothyroidism (TR/TSH deficiency)
Hyperthyroidism
Thyroid nodule
Precocious puberty
Gonadal dysfunction/failure
Gonadotropin deficiency (LH/FSH deficiency) [central gonadal failure]
Gonadal dysfunction – testicular: See Reproductive (male)
Gonadal dysfunction – ovarian: See Reproductive (female)
Metabolic syndrome
Overweight (Age 2-20 yrs: BMI for age >85 - <95%ile; Age >20 yrs: BMI 25 to 29.9)
Obesity (Age 2-20 yrs: BMI for age >95%ile; Age >20 yrs, BMI >30)
Underweight (FTT)
Insulin resistance
Impaired glucose tolerance
Diabetes mellitus
Type I
Type II
Gestational
Dyslipidemia
Adrenal insufficiency
Primary adrenal insufficiency (adrenal gland failure)
Secondary (central) adrenal insufficiency (ACTH deficiency)
Hyperprolactinemia
Growth deceleration
Growth hormone deficiency
Short stature (<5th percentile)
Endocrine/metabolic complication, other, specify:
Musculoskeletal
Amputation, specify type and site:
Osteonecrosis (avascular necrosis – AVN), specify site:
Craniofacial abnormalities
Impaired cosmesis
Contractures
Functional and activity limitation, specify:
Hypoplasia, specify site:
Kyphosis
Limb length discrepancy
Limb salvage, specify type and site:
Osteopenia
Osteoporosis
Phantom pain
Prosthesis, malfunction (poor fit, loosening, non-union, fracture)
Prosthesis, revision required due to growth
Residual limb integrity problems
Fracture (radiation-induced)
Increased energy expenditure (related to amputation/limb salvage)
Fibrosis (musculoskeletal)
Scoliosis
Short stature
Shortened trunk height
Reduced/uneven growth
Musculoskeletal complication, other, specify:

Summary Form - KeyPage 11

#17: Complications/Late Effects (by system, continued)
Central Nervous System (CNS)
Clinical leukoencephalopathy
With imaging abnormalities
Without imaging abnormalities
Learning disorder/disability
MathReading
Other, specify:
Motor deficit
Neurocognitive deficit, specify:
Diminished IQ
Executive function (planning/organization)
Sustained attention
MemoryProcessing speed
Visual-motor integration
MoyamoyaAtaxiaMovement disorder
Neurogenic bladder
Neurogenic bowel
Paralysis
Occlusive cerebral vasculopathy
Seizures
StrokeCNS complication, other, specify:
Peripheral Nervous System (PNS)
Peripheral sensory neuropathy
Peripheral motor neuropathy
PNS complication, other, specify:
Urinary
Hydronephrosis, specify: Right, left, bilateralHypertension
MononephricRenal insufficiency
Renal glomerular disorder
Hyperfiltration
Renal tubular disorder
Hypophosphatemic rickets
Renal Fanconi syndrome
Renal tubular acidosis
Vesicoureteral reflux
Bladder fibrosis
Urinary incontinence
Reservoir calculi
Dysfunctional voiding
Hemorrhagic cystitis
Proteinuria
Chronic UTI
Neobladder perforation
Urinary tract obstruction (due to retroperitoneal fibrosis)
Stricture, urinary tract, specify:
Urinary complication, other, specify:

Summary Form - KeyPage 12

#17: Complications/Late Effects (by system, continued)
Reproductive - Female
Breast tissue hypoplasia
Uterine vascular insufficiency
Adverse pregnancy outcome
Pregnancy complications
Delivery complications
Fetal malposition
Low birthweight infant
Spontaneous abortion
Premature labor
Neonatal death
Gonadal dysfunction - ovarian
Primary ovarian failure
Delayed/arrested pubertyPremature menopause
Infertility
Inability to conceive (despite normal ovarian function)
Dyspareunia
Symptomatic ovarian cysts
Pelvic adhesions
Sexual dysfunction
Vaginal stenosis/fibrosis
Reproductive - Male
Gonadal dysfunction - testicularGerm cell failure
Azoospermia
Oligospermia
Infertility
Leydig cell failure
Hypogonadism (testosterone deficiency)
Delayed/arrested puberty
Sexual dysfunction - male
Erectile dysfunction
Anejaculation
Retrograde ejaculation
Hydrocele
Dermatologic
Alopecia (permanent)
Dysplastic nevi
Altered skin pigmentation
Skin fibrosis
Nail dysplasia
Scleroderma
Telangiectasia
Vitiligo
ImmuneAsplenia
Functional asplenia
Surgical asplenia
History of life-threatening infection related to asplenia
Chronic sinusitis
Chronic graft versus host disease (GVHD)
Chronic Hepatitis B
Chronic Hepatitis C

Summary Form - KeyPage 13

#17: Complications/Late Effects (by system, continued)
Chronic infection, specify:
Human immunodeficiency virus (HIV) infection
Hypogammaglobulinemia
Secretory IgA deficiency
Pain, chronic
Musculoskeletal
Neuropathic
Other, specify:
Other, specify
No late effects identified
Unknown

Summary Form - KeyPage 14

Long-Term Follow-Up Guidelines
for Survivors of Childhood, Adolescent,and Young Adult Cancers
Version 2.0 – March 2006

Tools for
Guideline Application

Copyright 2006 © Children’s Oncology GroupAll rights reserved worldwide

Patient-Specific Guideline Identification Tool
(Applicable Guideline Sections indicated in Bold/Red; M = Male; F = Female)
Name:

Sex: M/F

Date of Birth:

Cancer Diagnosis: _________________

Date of Diagnosis: ________End Therapy Date: _____________

 Sections 1 & 2 applicable to all patients

CHEMOTHERAPY:Yes

No If yes:

Chemotherapy Agent(if patient received)

Prior to 1972:

Section 3

Prior to 1993:

Section 4

1977 - 1985:

Section 5

LTFU guidelines are applicable to patients who are>2 years following completion of cancer therapy

 Section 6 and applicable guidelines for specific chemotherapy agents below
Applicable guideline sections

Asparaginase

Section 34

Bleomycin

Section 29

BusulfanSections 7M/F, 8, 9, 10

Carboplatin – all doses

Sections 7M/F, 8, 15, 16, 17– myeloablative dose

See also: Section 14

Note: Myeloablative dose = conditioning for HCT

Carmustine

Sections 7M/F, 8, 9

Chlorambucil

Sections 7M/F, 8

Cisplatin

Sections 7M/F, 8, 14, 15, 16, 17

Cyclophosphamide

Sections 7M/F, 8, 11, 12

Cytarabine: SQ, IT, IO, low-dose IV

Section 20

Note: Low-dose IV = all single doses < 1000 mg/m2

Cytarabine: High-dose IV

Sections 18, 19

Note: High-dose IV = any single dose >1000 mg/m2

Dacarbazine

Sections 7M/F, 8

Dactinomycin

Section 30

Daunorubicin

Sections 27, 28

Cumulative dose: ______mg/m2
Age at first dose: ______
Dexamethasone

Sections 31, 32, 33

Doxorubicin

Sections 27, 28

Cumulative dose: ______mg/m2
Age at first dose: ______
Epirubicin*

Sections 27, 28

Cumulative dose: ______mg/m2

Cumulative dose x 0.67 = _______ mg/m2 = doxorubicin/daunorubicin isotoxic dose

Age at first dose: ______
Etoposide (VP-16)

Section 37

Idarubicin*

Sections 27, 28

Cumulative dose: ______mg/m2

Cumulative dose x 5 =_______ mg/m2= doxorubicin/daunorubicin isotoxic dose

Age at first dose: ______
Ifosfamide

Sections 7M/F, 8, 11, 13

Lomustine

Sections 7M/F, 8, 9

Mechlorethamine

Sections 7M/F, 8Melphalan

Sections 7M/F, 8

Mercaptopurine (6-MP)

Section 21*Use formulas below to convert to doxorubicin/daunorubicin isotoxic equivalents prior to calculating total cumulative anthracycline dose:
Epirubicin - multiply total dose x 0.67

Idarubicin - multiply total dose x 5

Mitoxantrone - multiply total dose x 3.5

Note: There is a paucity of literature to support isotoxic dose conversion; however, the above conversion factors may be used for conveniencein order to gauge screening frequency. Clinical judgment should ultimately be used to determine indicated screening for individual patients.

Page 1 of 5

Identification Tool
Page 1

Chemotherapy Agent (con’t)(if patient received)

Applicable guideline sections

Methotrexate: PO, IM, low and high-dose IV

Sections 22, 23, 24

Methotrexate: High-dose IV, IT, IO

Sections 25, 26

Mitoxantrone* (see footnote on previous page)

Sections 27, 28

Cumulative dose: ______mg/m2

Cumulative dose x 3.5 =Note: High-dose IV = any single dose >1000 mg/m2_______ mg/m2 = doxorubicin/daunorubicin isotoxic dose

Age at first dose: _________
Prednisone

Sections 31, 32, 33

Procarbazine

Sections 7M/F, 8

Temozolomide

Sections 7M/F, 8

Teniposide (VM-26)

Section 37

Thioguanine (6-TG)

Section 21

Thiotepa

Sections 7M/F, 8

Vinblastine

Sections 35, 36

Vincristine

Sections 35, 36
2

Total anthracycline cumulative dose (doxorubicin/daunorubicin isotoxic equivalent) = _________ mg/m
(Instructions: Add all anthracycline doses from boxes in above table to obtain total cumulative dose)
2
Note: For doses in mg/kg, multiply by 30 to obtain equivalent dosing in mg/m
RADIATION:

Yes

No

If yes: Sections 38 & 39 and applicable guidelines for specific fields below(Note: See instructions at end of this form)†

Radiation by field (all that apply)

Applicable guideline sections

Total body irradiation (TBI)

Any dose

Sections 42, 43, 49, 50, 56, 60, 62, 63, 64, 69F, 70, 79, 83F, 84F, 86M

Any radiation except TBI

Any dose

Sections 40, 41

CranialAny dose

Sections 42, 43, 44, 46, 47, 48, 49, 50, 51, 56, 59, 60, 62, 63, 64> 30 Gy

Sections 57, 58> 40 Gy

Sections 45, 52, 53, 54, 55, 61, 65, 66

Any dose

Sections 42, 46, 47, 48, 49, 50, 51, 56> 30 Gy

Section 57> 40 Gy

Sections 45, 52, 53, 54, 55

Any dose

Sections 42, 43, 46, 47, 48, 49, 50, 51> 30 Gy

Section 58> 40 Gy

Sections 45, 52, 53, 54, 55

Any dose

Sections 42, 46, 47, 48, 49, 50, 51, 59, 60, 62, 63, 64

Orbital/Eye

Ear/Infratemporal

Nasopharyngeal

Oropharyngeal

Spine (cervical)†> 30 Gy

Section 58> 40 Gy

Sections 45, 52, 53, 54, 55, 61, 65, 66

Any dose

Sections 59, 60, 62, 63, 64> 40 Gy

Section 61, 65, 66

Any dose

Sections 59, 60, 62, 63, 64> 12 Gy

Section 88> 30 Gy

Section 73> 40 Gy

Sections 61, 65, 66, 67, 91

Note: Total dose to each field should include boost dose, if given

Identification Tool
Page 2†

Radiation by field con’t (all that apply)

Applicable guideline sections

Spine (thoracic)

Any dose

Section 71> 12 Gy

Sections 88, 89> 30 Gy

Sections 73, 76, 77, 78, 90> 40 Gy

Section 91> 12 Gy

Sections 88, 89> 25 Gy

Sections 83F, 84F> 30 Gy

Sections 76, 77, 78> 40 Gy

Section 91> 12 Gy

Sections 88, 89> 25 Gy

Sections 83F, 84F> 30 Gy

Sections 76, 77, 78, 80, 81, 82> 40 Gy

Section 91

Any dose

Sections 59, 60, 62, 63, 64, 88> 30 Gy

Section 73> 40 Gy

Sections 61, 65, 66, 67, 91

Any dose

Sections 59, 60, 62, 63, 64, 88

Age at time of XRT: ______

Spine (lumbar)

Spine (sacral)

Cervical (neck)

Supraclavicular> 30 Gy

Section 73> 40 Gy

Sections 61, 65, 66, 67, 91

MantleAny dose

Sections 59, 60, 62, 63, 64, 69F, 70, 71, 88, 89, 90

Age at time of XRT: ______> 20 Gy

Section 68F> 30 Gy

Section 73> 40 Gy

Sections 61, 65, 66, 67, 91

Any dose

Sections 59, 60, 62, 63, 64, 69F, 88, 89, 90> 20 Gy

Section 68F> 30 Gy

Section 73> 40 Gy

Sections 61, 65, 66, 67, 91

Mediastinal

Any dose

Section 69F, 70, 71, 88, 89, 90

Age at time of XRT: ______> 20 Gy

Section 68F> 30 Gy

Section 73> 40 Gy

Section 91

Chest (thorax)

Any dose

Sections 69F, 70, 71, 88, 89, 90

Age at time of XRT: ______> 20 Gy

Section 68F> 30 Gy

Section 73> 40 Gy

Section 91

AxillaAny dose

Sections 69F, 71, 88

Age at time of XRT: ______> 20 Gy

Section 68F> 40 Gy

Section 91

Whole lungAny dose

Sections 69F, 70, 88, 89, 90

Whole abdomen

Any dose

Sections 71, 79, 82, 83F, 84F, 88, 89, 90

Age at time of XRT: ______> 30 Gy

Sections 73, 74, 75, 76, 77, 78, 80, 81> 40 Gy

Sections 72, 91

Mini-Mantle†

Note: Total dose to each field should include boost dose, if given

Identification Tool
Page 3†

Radiation by field con’t (all that apply)

Applicable guideline sections

Any upper abdominal field*

Any dose

Sections 71, 79 (except paraaortic), 88, 89, 90> 30 Gy

Sections 73, 74, 75, 76, 77, 78> 40 Gy

Section 91

Spleen (entire)> 40 Gy

See also: Section 72

Left upper quadrant> 40 Gy

See also: Section 72

Inverted Y> 40 Gy

See also: Section 72

Any pelvic field**Any dose

Sections 82, 83F (except iliac/inguinal), 84F, 85F, 86M, 88, 89> 20 Gy

Section 87M

Age at time of XRT: ______

Testicular

Extremity†> 30 Gy

Sections 76, 77, 78, 80, 81> 40 Gy

Section 91

Any dose

Section 86M> 20 Gy

Section 87M

Any dose

Section 88> 40 Gy

Section 91

Note: Total dose to each field should include boost dose, if given*Upper abdominal fields include: Hepatic, hemiabdomen/flank, upper quadrant, renal bed, spleen (partial, entire), splenic pedicle, inverted Y,
and paraaortic.
**Pelvic fields include: Pelvic, vaginal, prostate, bladder, iliac, inguinal, femoral and inverted Y; hemiabdominal included only if field
extended below iliac crest

HEMATOPOIETIC CELL TRANSPLANT:Yes

No If yes: Sections 92-97

If yes, did patient develop chronic graft-versus-host disease (cGVHD)?

SURGERY:

Yes

No

Yes

No If yes:  Sections 98-106(103 – active cGVHD; 105F - females)

If yes, include applicable guideline sections below:

Surgical procedure (if patient received)

Applicable guideline sections

Amputation

Section 107

Central venous catheter

Section 108

Cystectomy

Sections 109, 126, 127, 128M/F, 129M

Enucleation

Section 110

Hysterectomy

Section 111F (see also oophorectomy, if applicable, section 123F or 124F)

Laparotomy

Section 112

Limb sparing procedure

Section 113

Nephrectomy

Section 114

Neurosurgery - brain

Sections 115, 116, 117, 118

Neurosurgery - spinal cord

Sections 119, 120, 121M/F

Oophoropexy

Section 122F

Oophorectomy - unilateral

Section 123F

Oophorectomy - bilateral

Section 124F

Orchiectomy

Section 125M

Pelvic surgery

Sections 126, 127, 128M/F, 129M

Pulmonary lobectomy, metastasectomy
and/or wedge resection

Section 130

Splenectomy

Section 131

Thyroidectomy

Section 132

Identification Tool
Page 4OTHER THERAPEUTIC MODALITIES:YesOther Therapeutic Modality(if patient received)No

If yes, include applicable guideline sections below:

Applicable guideline sections

Radioiodine therapy (I-131 thyroid ablation)

Sections 133, 134

Systemic MIBG (in therapeutic doses)

Section 135

Bioimmunotherapy

Section 136

CANCER SCREENING GUIDELINES
Patient type

Cancer type

All patients

Colorectal

Age at first screening
Standard risk: Age 50 years

Applicable guideline sections (as indicated)
Section 139

Highest risk:
XRT: Age 35 or 10 years after XRT(whichever occurs last)
HNPCC: Puberty
FAP: Age 21 years
IBD: 8 years after diagnosis

Females

Lung

Highest risk: At entry into LTFU

Section 141

Oral

Highest risk: At entry into LTFU

Section 142

Skin

Highest risk: At entry into LTFU

Section 144

Standard risk: Age 20 years

Section 137F

BreastHighest risk: At puberty

Males

CervicalAll females: 3 years after first vaginal
intercourse, or age at 21, whicheveroccurs first

Section 138F

Endometrial

Highest risk: Age 35 years

Section 140F

Prostate

Males >45 years (see guideline)

Section 143M

Testicular

N/A (see guideline)

Section 145M

GENERAL HEALTH SCREENING
All patients

Section 146

Instructions for Radiation sections
If patient received radiation dose > minimum dose listed, select all applicable guideline sections listed for doses up to but
not exceeding dose received.
Example: If patient received 35 Gy and the following options are listed: “Any dose”, “>20 Gy”, “>30 Gy”, and “>40 Gy”, theapplicable guidelines for this patient include those listed for “Any dose”, “20 Gy” and “30 Gy”, but not for “40 Gy”.
If patient received radiation to the indicated field, but the total dose received was less than the minimum dose listed,no guidelines from that section are applicable to the patient.
Example: If patient received 10 Gy and the following options are listed “>12 Gy”, “>25 Gy”, “>30 Gy”, no guidelines in thissection are applicable to this patient.

Identification Tool
Page 5

Index to "Health Links" by Guideline Section NumberyGuideline
Section(s)1Health Link Abbreviated Title

Health Link - Full Title

Introduction toLong-Term Follow-Up

Introduction to Long-Term Follow-Up after
Treatment for Childhood, Adolescent, or Young
Adult Cancer

Emotional Issues

Emotional Issues after Childhood Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

Chronic Pain

Chronic Pain after Childhood Cancer

2

Finding Healthcare

Finding and Paying for Healthcare after Treatment
for Childhood Cancer

3

Hepatitis

Hepatitis after Childhood Cancer

4

Hepatitis

Hepatitis after Childhood Cancer

6

Dental Health

Dental Health Following Childhood Cancer
Treatment

7 (male)Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

7 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

8

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

9

Pulmonary HealthPulmonary Health

10

Cataracts

Cataracts after Treatment for Childhood Cancer

11

Bladder Health

Bladder Health After Childhood Cancer

12

Bladder Health

Bladder Health After Childhood Cancer

13

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

Hearing Loss

Hearing Loss after Treatment for Childhood
Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

15

Peripheral Neuropathy

Peripheral Neuropathy

16

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

17

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

18

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

21

Liver Health

Liver Health after Childhood Cancer

22

Bone Health

Keeping Your Bones Healthy after Childhood
Cancer23

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

14

Health Link Index
Page 1

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

24

Liver Health

Liver Health after Childhood Cancer

25

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

27

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

28

Heart Health

Keeping Your Heart Healthy after Treatment forChildhood Cancer

29

Pulmonary HealthPulmonary HealthBleomycin Alert

Bleomycin Alert

31

Bone Health

Keeping Your Bones Healthy after Childhood
Cancer32

Osteonecrosis

Osteonecrosis

33

Cataracts

Cataracts after Treatment for Childhood Cancer

35

Peripheral Neuropathy

Peripheral Neuropathy

36

Raynaud’s Phenomenon

Raynaud’s Phenomenon

37

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

38

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

39

Skin HealthSkin Health after Childhood Cancer

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

40

Skin HealthSkin Health after Childhood Cancer

43

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

48

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

49

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

50

Growth Hormone
Deficiency

Endocrine Problems after Childhood Cancer:
Growth Hormone Deficiency

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

51

Precocious Puberty

Endocrine Problems after Childhood Cancer:
Precocious Puberty

52

Hyperprolactinemia

Endocrine Problems after Childhood Cancer:
Hyperprolactinemia

53

Thyroid Problems

Thyroid Problems after Childhood Cancer

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

Central Adrenal
Insufficiency

Endocrine Problems after Childhood Cancer:
Central Adrenal Insufficiency

Hypopituitarism

Endocrine Problems after Childhood Cancer:
Hypopituitarism

54 (male)

54 (female)55

Health Link Index
Page 2

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

56

Cataracts

Cataracts after Treatment for Childhood Cancer

57

Eye Health

Keeping Your Eyes Healthy after Treatment forChildhood Cancer

58

Hearing Loss

Hearing Loss after Treatment for Childhood
Cancer

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

59

Dental Health

Dental Health Following Childhood Cancer
Treatment

60

Dental Health

Dental Health Following Childhood Cancer
Treatment

61

Osteoradionecrosis

Osteoradionecrosis after Childhood Cancer

62

Thyroid Problems

Thyroid Problems after Childhood Cancer

63

Thyroid Problems

Thyroid Problems after Childhood Cancer

64

Thyroid Problems

Thyroid Problems after Childhood Cancer

65

Thyroid Problems

Thyroid Problems after Childhood Cancer

68 (female)

Breast Cancer

Breast Cancer following Treatment for Childhood
Cancer: Are You at Risk?

70

Pulmonary HealthPulmonary Health

71

Heart Health

Keeping Your Heart Healthy after Treatment forChildhood Cancer

Diet and Physical Activity

Staying Healthy through Diet and Physical Activity

72

Splenic Precautions

Precautions for People Without a Functioning
Spleen73

GI Health

Gastrointestinal Health after Childhood Cancer

74

Liver Health

Liver Health after Childhood Cancer

75

GI Health

Gastrointestinal Health after Childhood Cancer

76

GI Health

Gastrointestinal Health after Childhood Cancer

77

GI Health

Gastrointestinal Health after Childhood Cancer

78

Colorectal Cancer

Colorectal Cancer Following Treatment forChildhood Cancer: Are You at Risk?

79

Kidney Health

Kidney Health after Childhood Cancer

Single Kidney Health

Keeping Your Single Kidney Healthy(for mononephric patients only)

80

Bladder Health

Bladder Health After Childhood Cancer

81

Bladder Health

Bladder Health After Childhood Cancer82

Bladder Health

Bladder Health After Childhood Cancer

83 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

84 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

86 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

87 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

Health Link Index
Page 3

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

89

Scoliosis and Kyphosis

Scoliosis and Kyphosis after Treatment forChildhood Cancer

90

Scoliosis and Kyphosis

Scoliosis and Kyphosis after Treatment forChildhood Cancer

92

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

93

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

95

Liver Health

Liver Health after Childhood Cancer

GI Health

Gastrointestinal Health after Childhood Cancer

96

Osteonecrosis

Osteonecrosis

97

Bone Health

Keeping Your Bones Healthy afterChildhood Cancer

98

Skin HealthSkin Health after Childhood Cancer

99

Eye Health

Keeping Your Eyes Healthy after Treatment
for Childhood Cancer

100

Dental Health

Dental Health Following Childhood Cancer
Treatment

101

Pulmonary HealthPulmonary Health103

Splenic Precautions

Precautions for People Without a Functioning
Spleen104

GI Health

Gastrointestinal Health after Childhood Cancer

107

Amputation

Late Effects after Amputation for Childhood
Cancer109

Cystectomy

Cystectomy and Childhood Cancer

Kidney Health

Kidney Health after Childhood Cancer

110

Eye Health

Keeping Your Eyes Healthy after Treatment forChildhood Cancer

111 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

112

GI Health

Gastrointestinal Health after Childhood Cancer

113

Limb Sparing Procedures

Limb Sparing Procedures after Bone Cancer

114

Single Kidney Health

Keeping Your Single Kidney Healthy

Kidney Health

Kidney Health after Childhood Cancer

115

Educational Issues

Educational Issues Following Treatment forChildhood Cancer

119

Neurogenic Bladder

Neurogenic Bladder Following Treatment forChildhood Cancer

121 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

123 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

124 (female)

Female Health Issues

Female Health Issues after Treatment forChildhood Cancer

125 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

128 (male)

Male Health Issues

Male Health Issues after Treatment forChildhood Cancer

Health Link Index
Page 4

Guideline
Section(s)Health Link Abbreviated Title

Health Link - Full Title

130

Pulmonary HealthPulmonary Health131

Splenic Precautions

Precautions for People Without aFunctioning Spleen

132

Thyroid Problems

Thyroid Problems after Childhood Cancer

134

Thyroid Problems

Thyroid Problems after Childhood Cancer

135

Thyroid Problems

Thyroid Problems after Childhood Cancer

137 (female)

Breast Cancer

Breast Cancer following Treatment for Childhood
Cancer: Are You at Risk?

138 (female)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

139

Colorectal Cancer

Colorectal Cancer Following Treatment forChildhood Cancer: Are You at Risk?

140 (female)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

141

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

142

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

Dental Health

Dental Health Following Childhood Cancer
Treatment

143 (male)

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

144

Reducing Risk of Cancers

Reducing the Risk of Second Cancers

Skin HealthSkin Health after Childhood Cancer

Health Link Index
Page 5