Implementing Cancer Survivorship Care Planning Workshop Summary (2007) / Chapter Skim
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Appendix F Treatment Summary Forms Developed by the Children’s Oncology Group (COG)
Appendix F Treatment Summary Forms Developed by the Children’s Oncology Group (COG)
Pages 288-306
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Appendix F Treatment Summary Forms Developed by the Children's Oncology Group (COG)
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HEMATOPOIETIC CELL TRANSPLANT Yes No If yes, answer question below Was this patient ever diagnosed with chronic graft-versus-host disease (cGVHD)
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Hispanic Native American/Alaskan Native Native Hawaiian/Pacific Islander Multi-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)
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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 Page 2 of 14
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TREATMENT SUMMARY FORMS DEVELOPED BY COG 295 #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, specify type:__________ Post-transplant lymphoproliferative disorder (PTLD) Lymphoma, other, specify: Sarcoma Ewing's sarcoma/peripheral PNET Osteosarcoma Rhabdomyosarcoma Nonrhabdomyosarcomatous soft tissue sarcoma, specify type: 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: Page 3 of 14
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Fludarabine Fluorouracil Gemcitabine Hydrocortisone Hydroxyurea Idarubicin Ifosfamide Imatinib Mesylate Irinotecan Lomustine (CCNU) Mechlorethamine Melphalan Mercaptopurine Methotrexate If IV: Any single dose >1000 mg/m2?
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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)
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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 Pelvis Pelvic Vagina Prostate Bladder Iliac Inguinal Femoral Inverted 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)
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Cyclophosphamide Etoposide Fludarabine Melphalan Thiotepa TBI Other, specify: None Unknown #14: GVHD Prophylaxis/Treatment ATG Cyclosporine Methotrexate MMF (mycophenolate mofetil) Prednisone PUVA Sirolimus Tacrolimus Other, specify: None Unknown Page 7 of 14
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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 Page 8 of 14
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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?
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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 Fistula Malabsorption Nutritional deficiency Vitamin B12, folate or carotene deficiency Cirrhosis Hepatic fibrosis Hepatic dysfunction Chronic hepatitis (non-infectious) Iron overload Venocclusive disease (VOD)
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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)
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Sustained attention Memory Processing speed Visual-motor integration Moyamoya Ataxia Movement disorder Neurogenic bladder Neurogenic bowel Paralysis Occlusive cerebral vasculopathy Seizures Stroke CNS complication, other, specify: Peripheral Nervous System (PNS) Peripheral sensory neuropathy Peripheral motor neuropathy PNS complication, other, specify: Urinary Hydronephrosis, specify: Right, left, bilateral Hypertension Mononephric Renal insufficiency Renal glomerular disorder Hyperfiltration Renal tubular disorder Hypophosphatemic rickets Renal Fanconi syndrome (dyselecrolytemia)
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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 Immune Asplenia Functional asplenia Surgical asplenia History of life-threatening infection (OPSI)
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306 APPENDIX F 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 Page 14 of 14
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