Appendix I Materials for Clinical Applications

1 Long-Term Follow-Up Guidelinesfor Survivors of Childhood, Adolescent, and Young Adult CancersVersion 2013 Copyright 2013 Children s Oncology GroupAll rights reserved worldwideAppendix IMaterials for Clinical ApplicationsCOG LTFU Guidelines 8 Page 2 Version October 2013 ContentsContentsReference Materials 3 Abbreviations4 Chemotherapy Agents7 Summary of Cancer Treatment8 Instructions9 Summary Form Template (Abbreviated)11 Summary Form Template (Comprehensive)12 Summary Form Key14 Patient-Specific Guideline Identification Tool23 Instructions24 Patient-Specific Guideline Identification Tool (version )25 Section Number Comparison COG LTFU Guidelines Version vs Reference Guide36 Contents37 Determining Applicability of Radiation Sections for Specific Patients Based on Exposure30 Radiation Dose Calculation Examples39 Radiation Fields Defined40 Radiation Fields by Anatomic Region41 Guideline Radiation Section Numbers by Anatomic Region42 Total Body Irradiation43 Skin, Bones, Soft Tissues44 Brain/Neuroendocrine Axis, Cranium, Face, Eye, Ear45 Oral Cavity46 Neck/Thyroid47 Breast48 Lungs49 Heart50 Spleen 51 Esophagus52 Liver53 Bowel54 Kidneys55 Bladder/Urinary Tract56 Female Reproductive System57 Male Reproductive System58 Musculoskeletal System (Growth Problems, Radiation-Induced Fracture)59 Musculoskeletal System (Scoliosis/Kyphosis)

2 60 Long-Term Follow-Up Guidelinesfor Survivors of Childhood, Adolescent, and Young Adult CancersVersion 2013 Copyright 2013 Children s Oncology GroupAll rights reserved worldwideReference Materials COG LTFU Guidelines Reference Materials Page 4 Version October 2013 AbbreviationsAbbreviationsAbbreviationDe finitionAAP-CIDPA merican Academy of Pediatrics Committee on Infectious Disease Prevention ABRB rainstem auditory evoked responsesAFPA lpha fetoproteinACSA merican Cancer SocietyAHAA merican Heart AssociationA LTAlanine aminotransferaseASTA spartate aminotransferaseATMA taxia telangiectasia cancer susceptibility gene located on chromosome 11 AVNA vascular necrosisBAERB rainstem auditory evoked responsesBCNUC armustine BMDBone mineral densityBMIBody mass indexBRCA1 Breast cancer, early onset gene (cancer susceptibility gene located on chromosome 17)BRCA2 Breast cancer 2, early onset gene (cancer susceptibility gene located on chromosome 13)BUNB lood urea nitrogenCaCalciumCBCC omplete blood countCCGC hildren s Cancer GroupCCNUL omustineCD-4 Cluster of differentiation antigen associated with helper T lymphocyteCDCC enters for Disease ControlcGVHDC hronic graft versus host diseaseClChlorideCNSC entral nervous systemCO2 Carbon dioxideCOGC hildren s Oncology GroupCSFC erebral spinal fluidCTComputed tomographyCXRC hest radiographDESD iethylstilbestrolDEXADual energy x-ray absorptiometryDLCOD iffusion capacity of carbon monoxideDOED yspnea on exertionEBMTE uropean Group for Blood and Marrow TransplantECHOE chocardiogramEKGE lectrocardiogramEIAE nzyme immunoassayFAPF amilial adenomatous polyposisFNAFine needle aspirateFSHF ollicle stimulating hormoneGHGrowth hormoneGVHDG raft versus host diseaseCOG LTFU Guidelines Reference Materials Page 5 Version October 2013 AbbreviationsAbbreviationDefinitionGyGra yHBcAbHepatitis B core antibody HBsAgHepatitis B surface antigenHCTH ematopoietic cell transplantHCVH

3 Epatitis C virusHDLHigh-density lipoproteinsHIBH aemophilus influenza BHIVH uman immunodeficiency virusHNPCCH ereditary nonpolyposis colorectal cancerHPFHigh power fieldHPVH uman papilloma virusHRTH ormonal replacement therapyHzHertzIBDI nflammatory bowel diseaseKPotassiumI-131 Iodine 131 radioisotopeIQIntelligence quotientITIntrathecalIVIntravenousIVIGI ntravenous immunoglobulinKUBK idneys, ureters, bladder radiographLHLuteinizing hormoneMIBGI odine-131-meta-iodobenzylguanidineMgMagn esiumMOPPM echlorethamine, Oncovin, Procarbazine, PrednisoneMRIM agnetic resonance imagingMUGAM ultiple Gated Acquisition scanNaSodiumNCEPN ational Cholesterol Education ProgramNCHSN ational Center for Health StatisticsNF1 Neurofibromin 1 (neurofibromatosis) cancer susceptibility gene located on chromosome 17 NSAIDsNon-steroidal anti-inflammatory drugsOAEO toacoustic emissionsOCPOral contraceptive pillsPAPP apanicoulauPCRP olymerase chain reactionPFTsPulmonary function testsp53 Cancer susceptibility gene located on chromosome 17 associated with familial cancers POBy mouthPO4 PhosphatePRNAs neededPSAP rostate specific antigenQCTQ uantitative computed tomographyAbbreviations (cont)

4 COG LTFU Guidelines Reference Materials Page 6 Version October 2013 AbbreviationsAbbreviationDefinitionQTcCo rrected QT interval RB1 Retinoblastoma gene cancer susceptibility gene located on chromosome 13 RBCRed blood cellRDAR ecommended daily allowanceRUQR ight upper quadrantSCUBASelf-contained underwater breathing apparatus SDStandard deviationSOBS hortness of breathT4 ThyroxineTBIT otal body irradiationTPNT otal parenteral nutritionTSHT hyroid stimulating hormoneU/AUrinalysisUSPSTFU nited States Preventive Services Task ForceVODVeno-occlusive diseaseVZIGV aricella zoster immunoglobulinAbbreviations (cont)COG LTFU Guidelines Reference Materials Page 7 Version October 2013 Chemotherapy AgentsGeneric NameAdditional Name(s)ClassificationAsparaginaseElspar Erwinia asparaginaseKidrolase L-asparaginaseOncaspar PEG-asparaginaseEnzymeBleomycinBlenoxane Anti-tumor antibioticBusulfanBusulfex BusulphanMyleran Alkylating agentCarboplatinCBDCAP araplatin Heavy metalCarmustineBCNUBiCNU Alkylating agentChlorambucilLeukeran Alkylating agentCisplatinCDDPC isplatinumPlatinol Heavy metalCyclophosphamideCPMC ytoxan Neosar Procytox Alkylating agentCytarabineAra-CCytosar Cytosar-U Cytosine arabinosideAntimetaboliteDacarbazineDTIC DTIC-Dome Non-classical alkylatorDactinomycinActinomycin-DCosmeg en Anti-tumor antibioticDaunorubicinCerubidine DaunomycinDaunoXome Anthracycline antibioticDexamethasoneDecadron CorticosteroidDoxorubicinAdriamycin Doxil Rubex Anthracycline antibioticEpirubicinEllence Pharmorubicin PFS Anthracycline antibioticEtoposideVePesid VP-16 EpipodophyllotoxinIdarubicinIdamycin Anthracycline antibioticIfosfamideIfex Alkylating agentLomustineCeeNU CCNUA lkylating

5 AgentMechlorethamineMustargen Nitrogen MustardAlkylating agentMelphalanAlkeran Alkylating agentChemotherapy AgentsGeneric NameAdditional Name(s)ClassificationMercaptopurine6-Mer captopurine6-MPPurinethol AntimetaboliteMethotextrateAmethopterinF olex Mexate Trexall AntimetaboliteMitoxantroneNovantrone Anthracycline antibioticPrednisoneDeltasone MethylprednisolonePrednisoloneCorticoste roidProcarbazineMatulane Natulan Alkylating agentTemozolomideTemodal Temodar Non-classical alkylatorTeniposideVM-26 Vumon EpipodophyllotoxinThioguanineLanvis Tabloid 6-Thioguanine6-TGAntimetaboliteThiotepaT hioplex Alkylating agentVinblastineVBLV elban Velbe Plant alkaloidVincristineOncovin VCRV incasar Vincrex Plant alkaloidLong-Term Follow-Up Guidelinesfor Survivors of Childhood, Adolescent, and Young Adult CancersVersion 2013 Copyright 2013 Children s Oncology GroupAll rights reserved worldwideSummary of Cancer TreatmentCOG LTFU Guidelines Summary of Cancer Treatment Page 9 Version October 2013 InstructionsSummary of Cancer Treatment InstructionsImportance of a Comprehensive Cancer Treatment SummaryThe Children s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are based on therapeutic exposures received during cancer treatment.

6 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 from the institution(s) where they received their treatment. Ideally, the comprehensive treatment summary should include the following information: Demographics (name, sex, date of birth, contact information) Diagnosis, including site/stage, date, and relapse(s) if any Pertinent secondary diagnoses ( , second malignancy, Down syndrome) Treatment protocol information, if applicable All chemotherapy agents received during treatment (including route of administration for all agents, cumulative doses for alkylators, bleomycin, and anthra-cyclines, and designation of high dose versus standard dose for methotrexate 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.

7 Standard dose methotrexate/cytarabine is defined as all single doses < 1000 mg/m2. See Section 33 (male) or 34 (female) 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). Radiation therapy summary, including field(s), laterality (if applicable), start/stop dates, number of fractions, dose per fraction, boost dose/location (if applica-ble), 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); for definition of radiation fields, see page 3 of the Radiation Reference Guide ( Appendix 1) Hematopoietic cell transplant(s), including type(s), date(s), conditioning regimen(s), and GVHD prophylaxis and/or treatment Surgical procedures, including date, site, and laterality if applicable Other therapeutic modalities ( , biologicals, systemic radiation) Significant complications/late effects with dates of onset/resolution Adverse drug reactions/allergiesMinimum Information Necessary to Generate Patient-Specific Guidelines:In order to generate accurate exposure-based follow-up recommendations from these guidelines, the following information regarding the survivor s diagnosis and treatment is required, at minimum: Survivor s sex Survivor s date of birth Date of cancer diagnosis Date cancer therapy was completed Names of all chemotherapy agents received.

8 Note: For a list of chemotherapy agents addressed by these guidelines (Sections 10 43), see the Chemother-apy portion of the Patient-Specific Guideline Identification Tool in Appendix 1. For generic and brand names of chemotherapy agents, see Chemotherapy Agents in Appendix 7. Cumulative dose of all anthracycline chemotherapy received ( , doxorubicin, daunorubicin, idarubicin, mitoxantrone and epirubicin), and age at first anth-racycline dose (if unknown, age at first anthracycline dose is presumed to be age at diagnosis). Note: For anthracycline isotoxic dose-equivalent conversion, see Sections 33 (male) or 34 (female) of Guidelines. 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 ( , given as conditioning for HCT). Whether survivor was < age 1 at time of diagnosis For cytarabine and methotrexate: Route of administration ( , 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) COG LTFU Guidelines Summary of Cancer Treatment Page 10 Version October 2013 Instructions (cont) All radiation field(s) and total radiation dose (in Gy) to each field.

9 For chest, thoracic spine, and 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 cGy or rads to Gy, divide dose by 100 (example: 2400 cGy = 2400 rads = 24 Gy). For list of radiation fields addressed by these guidelines (Sections 44 102), see Radia-tion portion of the Patient-Specific Guideline Identification Tool in Appendix 1; for definition of radiation fields, see page 3 of the Radiation Reference Guide ( Appendix 1) Whether or not the survivor underwent a hematopoietic cell transplant (HCT), and if so, whether or not the survivor developed chronic graft-versus-host disease (cGVHD). Names of all relevant surgical procedures. Note: For list of surgical procedures addressed by these guidelines (Sections 120 152), see Surgery portion of the Patient-Specific Guideline Identification Tool in Appendix 1. Names of all other therapeutic modalities.

10 Note: For list of other therapeutic modalities addressed by these guidelines (Sections 153 156), see Other Thera-peutic Modality portion of the Patient-Specific Guideline Identification Tool in Appendix for Summary of Cancer TreatmentTwo templates for summarizing cancer treatment are included in Appendix I (and also available in electronic format at ). These templates were originally developed by the COG Nursing Clinical Practice Subcommittee under the leadership 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, and meets the minimum data requirements for initial use of the Passport for Care web-based guideline interface.