Long-term Follow-up Guidelines Research Articles

Cardiac MRI use in the diagnosis of acute infectious myocarditis

Viral myocarditis is a prevalent disease amongst endemic nations. With increased opportunity of travel, and warmer climates for arthropod-vectors to spread, infectious myocarditis incidence is likely to rise as well. Acute manifestations of myocarditis include fevers, generalized weakness, myalgias, and arthralgias. While death is rare, long-term morbidity related to acute complications plus chronic cardiac structural changes can occur. No current guidelines for long-term myocarditis follow-up and designated treatment strategies exist, and future work in these areas is required.

Twenty-five years of duodenal switch. How to switch to the duodenal switch

Background: the duodenal switch (DS) is a procedure that combines a vertical gastrectomy (VG) plus a biliopancreatic diversion (BPD). Objectives: to report our experience in 950 consecutive DS patients with morbid obesity (MO) performed from 1994 to 2011, with 27 years of follow-up. Environment: mix of teaching and private institution in a regional hospital in Spain. Methods: retrospective review of 950 consecutive morbidly obese patients treated with DS surgery. Results: five hundred and eighteen open DS (ODS) and 432 laparoscopic DS (LDS) were performed. Operative mortality was 0.84% (1.38% in ODS and 0.38% in LDS); 4.84% had one leak, two had liver failure (0.2%) and malnutrition was present in 3.1%. At five years, the body mass index (BMI) percentage of lost overweight (%EWL) was 80% and the percentage of expected BMI loss was more than 100%. Conclusions: the DS is the most aggressive bariatric technique but with the best long-term weight loss. Operative complications and long-term follow-up guidelines are described.

Evidence for increased surveillance of executive functioning in adolescent and young adult survivors of childhood cancer.

Comprehensive long-term follow-up (LTFU) for survivors of childhood cancer is critical for reducing morbidity and mortality. Current standards recommend screening all survivors for psychological and academic problems and certain survivors for neurocognitive problems based upon treatment exposures. This study aimed to determine if differences exist in executive functioning (EF) based on treatment exposures and characterize relationships between EF, treatment exposure, and internalizing problems. Participants included adolescent and young adult (AYA) survivors (N = 70) of non-central nervous system cancer, aged 14-21 presenting for LTFU. Patient-reported data were obtained on survivors' EF, internalizing symptoms, academic performance, and educational supports. Children's Oncology Group's LTFU Guidelines classified survivors as at risk or not at risk for neurocognitive deficits based on treatment exposures. Group differences, relationships, and moderation by risk group were examined. No differences were found in EF, internalizing symptoms, academic performance, or educational supports between survivors who were at risk versus those not at risk for neurocognitive deficits. Problems with EF predicted internalizing symptoms, an effect that was moderated by risk group (R2= .64 for AYA self-report; R2 = .38 for parent-proxy report). Survivors with poorer EF experienced higher levels of internalizing symptoms. These data indicate that current screening practices may not identify survivors who are not at risk for neurocognitive deficits, yet struggle with EF. Survivor care providers should consider universal screening for EF problems in AYAs, regardless of treatment exposure history. Clinical assessment of internalizing problems in survivors with EF problems is also recommended.

Tailoring a Survivorship Care Plan: Patient and Provider Preferences for Recipients of Hematopoietic Cell Transplantation

This study aimed to develop a survivorship care plan (SCP) that can be individualized to facilitate long-term follow-up care of hematopoietic cell transplantation (HCT) survivors. A sample SCP was developed that included 2 documents: a treatment summary and preventive care recommendations that combined data on treatment exposures routinely submitted by HCT centers to the Center for International Blood and Marrow Transplant Research (CIBMTR) with long-term follow-up guidelines. Focus groups were conducted by phone to characterize the critical patient-centered elements of the SCP. Focus group eligibility criteria included (1) adult patients >1 year post-HCT and their caregivers (3 groups; n = 22), (2) HCT physicians and advanced practice providers (APPs) (2 groups; n = 14), (3) HCT nurses and social workers (4 groups; n = 17), and (4) community health care professionals (3 groups; n = 24). Transcripts were analyzed for saturation of key themes using NVivo 10 software. Patients and caregivers suggested combining the treatment summary and care guidelines into a single document. They also requested sections on sexual and emotional health and the immune system. Providers wanted the treatment summary to focus only on what they absolutely must know. Themes were similar across healthcare professionals, although screening for psychosocial issues was emphasized more by the nurses and social workers. All preferred to receive the SCP electronically; however, hardcopy was considered necessary for some patients. All felt that the SCP would facilitate appropriate post-HCT care. This study highlights the need for an SCP instrument to facilitate HCT survivorship care. Furthermore, it demonstrates the feasibility and value of engaging HCT recipients, caregivers, and providers in developing an SCP. Their feedback was incorporated into a final SCP that was subsequently tested in a randomized trial.

Impact of Guideline-Driven Approach in Follow-Up of Long-Term Complications After Allogeneic Hematopoietic Cell Transplant: Single Center Experience.

After allogeneic stem cell transplant, patients may experience psychiatric, endocrinologic, pulmonary, and cardiovascular problems, as well as secondary malignancies and chronic graft-versus-host disease over the long-term follow-up. These long-term complications not only increase mortality and morbidity of transplant survivors but also decrease their quality of life. In this study, we shared our experiences with our guideline-driven approach for follow-up of long-term complications. Our study included 91 patients who received allogeneic hematopoietic cell transplant between July 2009 and March 2016 at our medical center. In accordance with the current guidelines, a screening program was applied to all patients seen between February 2016 and February 2017. Median posttransplant follow-up duration was 36 months (range, 12-84 mo), and the median follow-up duration after initial diagnosis was 51 months (range, 15-109 mo). Evaluations of patients posttransplant showed ocular complications (50.6% of patients), oral complications (15.4%), respiratory complications (8.8%), cardiac complications (5.5%), metabolic syndrome (37.4%), liver complications (2.2%), skeletal complications (66.7%), endocrine complications (12.1%), secondary cancers (2.2%), psychosocial adjustment (27.7%), hypertension (5.5%), and type 2 diabetes mellitus (8.8%). For long-term follow-up, detailed evaluations of body organs and systems are essential. Early recognition of the aforementioned complications could decrease mortality and morbidity. For patients to be monitored by transplant centers over many years, training and awareness should be provided to ensure adequate follow-up of patients. Based on our results, we believe that the long-term follow-up guidelines used in our clinic are applicable to others.

Adherence to Children’s Oncology Group (COG) long-term follow-up guidelines for echocardiogram screening in young adult survivors of childhood cancer.

e22513Background: Late morbidity is of increasing importance with improved survival from childhood cancer. The COG Long-term Follow-up Guidelines recommend echocardiogram screening in patients who ...

Role of Germline Genetics in Identifying Survivors at Risk for Adverse Effects of Cancer Treatment.

The growing population of cancer survivors often faces adverse effects of treatment, which have a substantial impact on morbidity and mortality. Although certain adverse effects are thought to have a significant heritable component, much work remains to be done to understand the role of germline genetic factors in the development of treatment-related toxicities. In this article, we review current understanding of genetic susceptibility to a range of adverse outcomes among cancer survivors (e.g., fibrosis, urinary and rectal toxicities, ototoxicity, chemotherapy-induced peripheral neuropathy, subsequent malignancies). Most previous research has been narrowly focused, investigating variation in candidate genes and pathways such as drug metabolism, DNA damage and repair, and inflammation. Few of the findings from these earlier candidate gene studies have been replicated in independent populations. Advances in understanding of the genome, improvements in technology, and reduction in laboratory costs have led to recent genome-wide studies, which agnostically interrogate common and/or rare variants across the entire genome. Larger cohorts of patients with homogeneous treatment exposures and systematic ascertainment of well-defined outcomes as well as replication in independent study populations are essential aspects of the study design and are increasingly leading to the discovery of variants associated with each of the adverse outcomes considered in this review. In the long-term, validated germline genetic associations hold tremendous promise for more precisely identifying patients at highest risk for developing adverse treatment effects, with implications for frontline therapy decision-making, personalization of long-term follow-up guidelines, and potential identification of targets for prevention or treatment of the toxicity.

Late Infection-Related Mortality in Asplenic Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study.

Purpose Infection-related outcomes associated with asplenia or impaired splenic function in survivors of childhood cancer remains understudied. Methods Late infection-related mortality was evaluated in 20,026 5-year survivors of childhood cancer (diagnosed < 21 years of age from 1970 to 1999; median age at diagnosis, 7.0 years [range, 0 to 20 years]; median follow-up, 26 years [range, 5 to 44 years]) using cumulative incidence and piecewise-exponential regression models to estimate adjusted relative rates (RRs). Splenic radiation was approximated using average dose (direct and/or indirect) to the left upper quadrant of the abdomen (hereafter, referred to as splenic radiation). Results Within 5 years of diagnosis, 1,354 survivors (6.8%) had a splenectomy and 9,442 (46%) had splenic radiation without splenectomy. With 62 deaths, the cumulative incidence of infection-related late mortality was 1.5% (95% CI, 0.7% to 2.2%) at 35 years after splenectomy and 0.6% (95% CI, 0.4% to 0.8%) after splenic radiation. Splenectomy (RR, 7.7; 95% CI, 3.1 to 19.1) was independently associated with late infection-related mortality. Splenic radiation was associated with increasing risk for late infection-related mortality in a dose-response relationship (0.1 to 9.9 Gy: RR, 2.0; 95% CI, 0.9 to 4.5; 10 to 19.9 Gy: RR, 5.5; 95% CI, 1.9 to 15.4; ≥ 20 Gy: RR, 6.0; 95% CI, 1.8 to 20.2). High-dose alkylator chemotherapy exposure was also independently associated with an increased risk of infection-related mortality (RR, 1.9; 95% CI, 1.1 to 3.4). Conclusion Splenectomy and splenic radiation significantly increase risk for late infection-related mortality. Even low- to intermediate-dose radiation exposure confers increased risk, suggesting that the spleen is highly radiosensitive. These findings should inform long-term follow-up guidelines for survivors of childhood cancer and should lead clinicians to avoid or reduce radiation exposure involving the spleen whenever possible.

Late Effects Screening Guidelines after Hematopoietic Cell Transplantation (HCT) for Hemoglobinopathy: Consensus Statement from the Second Pediatric Blood and Marrow Transplant Consortium International Conference on Late Effects after Pediatric HCT

Allogeneic hematopoietic cell transplantation (HCT) can halt organ damage and eliminate symptoms in hemoglobin disorders, including sickle cell disease (SCD) and thalassemia major. Managing the residual manifestations of pre-HCT disease complications and the long-term effects of HCT requires systematic monitoring, follow-up and intervention when indicated. Late complications vary with age and disease status at HCT and with transplant variables such as preparative regimen, donor source and compatibility, and immune reconstitution. An international consensus conference sponsored by the Pediatric Blood and Marrow Transplant Consortium in May 2016 entitled “Late Effects Screening and Recommendations Following HCT for Immune Deficiency and Nonmalignant Hematologic Disorders” focused on follow-up after HCT for hemoglobinopathy. An earlier publication from experts who participated in this session described the pathophysiology and spectrum of complications that HCT recipients experience after HCT for SCD and thalassemia major. This companion publication summarizes the consensus reached by this group of experts about long-term follow-up guidelines after HCT for hemoglobinopathy. In addition, these guidelines might also be included in studies of novel curative therapies such as autologous HCT after hematopoietic progenitor stem cell gene modification.

Mini Review: Screening and Management of Late Effects in Patients with Severe Combined Immunodeficiency after Allogeneic Hematopoietic Cell Transplantation

Severe combined immunodeficiency (SCID) is a group of the most severe of primary immunodeficiencies and is typically fatal in the first year of life without hematopoietic cell transplantation (HCT). Improved transplantation techniques and supportive care measures have resulted in improved survival following HCT. Furthermore, patients are being diagnosed earlier since the widespread implementation of SCID newborn screening in the United States and moving on to transplantation before 3.5 months of age. As such, most SCID patients are now expected to live well into adulthood following successful HCT. Many centers are using conditioning with alkylating agents, including busulfan and melphalan, pre-transplantation to achieve full T and B cell immune reconstitution; however, significant concerns remain regarding the attendant risks of using chemotherapeutic agents in early infancy. Several long-term follow-up studies have demonstrated high rates of non-immunologic late effects depending on the conditioning regimen employed and SCID genotype. The full risk of conditioning in this patient population remains incompletely characterized, and further research on post-HCT outcomes is needed. It is imperative that all providers caring for SCID survivors both in childhood and adulthood be aware of the risk of late effects. Guidelines for long-term follow-up were recently published, and the recommendations are briefly summarized here.

Factors influencing risk-based care of the childhood cancer survivor in the 21st century.

The population of adult survivors of childhood cancer continues to grow as survival rates improve. Although it is well established that these survivors experience various complications and comorbidities related to their malignancy and treatment, this risk is modified by many factors that are not directly linked to their cancer history. Research evaluating the influence of patient-specific demographic and genetic factors, premorbid and comorbid conditions, health behaviors, and aging has identified additional risk factors that influence cancer treatment-related toxicity and possible targets for intervention in this population. Furthermore, although current long-term follow-up guidelines comprehensively address specific therapy-related risks and provide screening recommendations, the risk profile of the population continues to evolve with ongoing modification of treatment strategies and the emergence of novel therapeutics. To address the multifactorial modifiers of cancer treatment-related health risk and evolving treatment approaches, a patient-centered and risk-adapted approach to care that often requires a multidisciplinary team approach, including medical and behavioral providers, is necessary for this population. CA Cancer J Clin 2018;68:133-152. © 2018 American Cancer Society.

Long-term follow-up clinics after hematopoietic cell transplantation: its needs and challenges in Japan.

With a growing number of transplant survivors, long-term survivorship care has received more attention. In long-term survivors, mortality remains higher than that of the general population, and they are prone to a unique set of late complications. The common late effects are as follows: chronic graft-versus-host disease, organ failure, endocrine complication, secondary cancer, mental health problem, and financial burden due to factors including unemployment. Long-term follow-up (LTFU) clinic plays an important role in the screening and early intervention for late effects and in informing and supporting patients to improve their quality of life. The importance of LTFU has been recognized, and the guidelines for screening and preventive practices for long-term survivors after transplantation were first published in 2006 and updated in 2012 based on a consensus opinion of the international working group. The guidelines for LTFU have been recently published by the Japan society for hematopoietic cell transplantation; they highlight the recommended screening and intervention available in our country, utilizing the evidence on the late effects reported from our country and overseas. In this review, I would like to illustrate the background of the need for LTFU and discuss the challenges in operating an LTFU clinic to effectively provide physical, mental, and social care to transplant survivors.

Specialized survivor clinic attendance increases adherence to cardiomyopathy screening guidelines in adult survivors of childhood cancer.

To determine if attendance at a specialized clinic for adult survivors of childhood cancer is associated with better rates of adherence to the Children's Oncology Group (COG) Long-term Follow-up (LTFU) guidelines for cardiomyopathy screening. We conducted a retrospective population-based study using administrative data in Ontario, Canada of 5-year survivors diagnosed between 1986 and 2005 at risk of therapy-related late cardiomyopathy. Patients were classified into three groups based on the recommended frequency of screening: annual, every 2years, and every 5years. Of 1811 eligible survivors followed for median 7.8years (range 0-14.0), patients were adherent to screening for only 8.6% of their period of follow-up. Survivor clinic utilization had the strongest association with increased rates of adherence: when compared to no attendance, ≥5 clinic visits/10-year period had RR of adherence of 10.6 (95% CI 5.7-19.5) in the annual group, 3.3 (95% CI 2.3-4.8) in the every 2-year group, and 2.3 (95% CI 1.6-3.2) in the every 5-year group. Additional factors associated with increased adherence after adjusting for clinic attendance included annual assessment by a general practioner, female sex, diagnosis prior to 2003, and living in a rural area. In a model of specialized survivor care, increased clinic utilization is associated with improved patient adherence to COG LTFU cardiomyopathy screening guidelines. Specialized survivor clinics may improve health outcomes in survivors through improved adherence to screening. However, rates of adherence remain suboptimal and further multifacetted strategies need to be explored to improve overall rates of screening in adult survivors of childhood cancer.

Ototoxicity monitoring in children treated with platinum chemotherapy

Objective: To review the prevalence, mechanisms, clinical presentation, risk factors and implications of platinum-induced ototoxicity in paediatric cancer patients based on published evidence, discuss options for monitoring hearing in young children during treatment and review long-term follow-up guidelines. Design: Narrative literature review. Results: Children treated with cisplatin are at high risk of hearing loss and early, accurate identification of ototoxicity is important for medical decision making and hearing rehabilitation. Challenges of monitoring hearing in young children during cancer treatment and options for monitoring hearing are discussed. Conclusion: Hearing loss has important consequences for the survivors of childhood cancer including communication, learning, cognition and quality of life. Due to the presentation and configuration of ototoxic hearing loss, the test frequencies that are prioritised and the sequence of testing may differ from standard paediatric hearing evaluations. Hearing should be monitored during treatment and after completion of therapy.

Barriers and solutions of long-term follow up of childhood cancer survivors in Turkey: A questionaire survey.

e22020 Background: The population of childhood cancer survivors has grown with 80 % cure rates. Our aim was to establish the barriers of longterm followup (LTFU) in Turkey. Methods: An e-mail questionnaire survey has been sent to 33 pediatric oncology centers (POC). Questionnaire compossed of 3 sections: 1- Description of the center; yearly new patients number, follow-up period, etc. 2- Methods for follow-up of late effects Content of provided information to the families related cancer treatment &amp; side effects &amp; healthy life style, missing parts of LTFU 3- Transition problems of survivors to adult survivorship programs. Educational problems of Hematology/Oncology Fellows (HOF) Suggestions for improvement of LTFU. Results: 21 of 33 centers (63%) responded the questionnaire. Experience as POC: 2-50 years (median: 23). New patients / each year: 8 - 300 (median: 68). Most of the centers accepting patients up to 18 years, only 4 center providing lifelong LTFU. No Available Risk Adapted LTFU guideline at 21 center. LTFU provided by pediatric oncologist at the pediatric oncology outpatient clinic with transition problems to adult clinic. All centers were following Cardiotoxicity, Secondary cancer,and Kidney toxicity with no problem Barriers of Turkish POC for LTFU of Pediatric Cancer Survivors were: Lack of enough care providers 66%, lack of time 57%, transportation problems 57 % ,lack of providing knowledge to patients 38 %. Although 80 % of the centers have fellows for HOF, not enough edication on survivorship 66%, due to lack of survivorship clinic ( 80%), busy working schedules. Conclusions: Questionnaire survey was able to reach 2/3 the pediatric oncology centers that were located in 8 cities and following most of the pediatric oncology patients in Turkey Mostly POCs do not provide enough LTFU. All centers agree on national guidelines for LTFU. [Table: see text]

The Price of the Successful Treatment of Pediatric Malignancies.

Recent improvements in therapy of children with cancer have resulted in an increase in cure rates which lead to long-term survivorship. Assessment of short- and long-term complications and late effects of cancer therapies is accomplished by pediatric oncologists and multi-disciplinary team, including continuation of care from pediatric to adult primary care. The late complications of cancer treatment include growth and development, reproduction, vital organ function (cardiac, pulmonary, renal, gastrointestinal), dental, ocular, esthetic sequellae, and second neoplasms (benign or malignant), which are cited as the second most frequent cause of death in the Children Cancer Survivors Study cohort. Long-term follow-up guidelines for survivors of childhood cancers has been established by international specialists, the main aim is to decrease severe late complications by individualizing prevention care and treatment. Preventive measures include reduction of radiotherapy doses, or omission, introduction of new radiotherapy techniques, decrease doses of alkylating drugs, and anthracyclines, cardio protectors, fertility preservations guidelines, new surgical techniques, introduction of biological treatments. The multidisciplinary team monitors certain treatments including risk-based care not only of the tumor, but also premorbid conditions, and health behaviors. More comprehensive and high-quality evaluations of survivorship programs are needed, for long term outcome, quality of life and psychosocial support.

Understanding and Improving Knowledge of Cancer Survivorship Care Among College Providers.

This study aimed to assess college providers' basic knowledge of the health risks of young adult cancer survivors (YAS) and related care guidelines and to determine whether an educational in-service is an effective platform for increasing college health providers' knowledge about survivorship care at a large university health center. During phase 1, staff from college health centers and office of disabilities in the Philadelphia area (n=40 staff members from 24 colleges/universities) completed a needs assessment on their experiences with YAS and preferences for education and care coordination. During phase 2, a 1-h educational in-service, informed by results of the survey, was provided to 18 health center medical providers. While most providers indicated that YAS are at risk for chronic health conditions because of cancer treatment, nearly all were unfamiliar with the content of published long-term follow-up guidelines for cancer survivorship. Over half did not have knowledge of cancer survivorship services in their area. All respondents were interested in more education on cancer survivorship care. Attendees of the in-service increased their knowledge of survivorship follow-up guidelines, awareness of local survivorship resources, and comfort with caring for YAS at posttest relative to baseline. The in-service was highly acceptable to providers and feasible to implement. College providers had little baseline knowledge of cancer survivorship guidelines, but were motivated to obtain more information. Through an educational in-service, college health providers may be better equipped to provide acute and longitudinal survivorship care to a vulnerable population who are at risk for inadequate engagement in risk-based follow-up care.

Risk factors and surveillance for reduced bone mineral density in pediatric cancer survivors.

Pediatric cancer survivors are at increased risk of developing low bone mineral density (BMD) due to cancer treatment. This study assessed the yield of screening for low BMD in pediatric-aged cancer survivors as per the Children's Oncology Group Long-Term Follow-Up (COG-LTFU) Guidelines, which recommend screening survivors who received steroids, methotrexate, or hematopoietic cell transplant (HCT). This is a retrospective cohort study of 475 pediatric blood cancer and noncentral nervous system solid tumor survivors screened for low BMD with dual-energy X-ray absorptiometry (DXA) as per the COG-LTFU Guidelines from 2003 to 2010. Risk factors for low BMD (DXA Z-score ≤-2) were evaluated by univariate and multivariate analysis. The mean DXA Z-score was -0.1 for both whole body and lumbar spine measurements. Among at-risk survivors, 8.2% (39/475) had low BMD. Multivariate analysis of survivors with low BMD showed significant association with male gender (odds ratio [OR] 3.4, 95% confidence interval [CI], 1.3-9.0), exposure to total body irradiation (TBI), cranial, or craniospinal radiation (OR 5.2, 95% CI, 1.8-14.9), and gonadal dysfunction (OR 4.3, 95% CI, 1.4-13.0). Methotrexate exposure was not significantly associated with low BMD. Survivors receiving HCT had a reduced risk of low BMD (OR 0.2, 95% CI, 0.1-0.9). The highest risk factors for low BMD were male gender, exposure to TBI, cranial, or craniospinal radiation, and gonadal dysfunction. Survivors receiving methotrexate or HCT therapy have the lowest risk for low BMD among those screened. Future studies should investigate risk of low BMD for survivors receiving HCT without radiation exposure.

Understanding and improving knowledge of cancer survivorship care among college providers.

101 Background: Young adult survivor (YAS) engagement in follow-up care is often compromised by competing developmental transitions, including attending college away from home and pediatric oncology team, as well as community providers’ deficits in knowledge related to caring for YAS. The aims were to assess college providers’ basic knowledge of the risks of YAS and related care guidelines and determine whether an educational in-service is an effective platform for increasing college health providers’ knowledge about survivorship. Methods: During Phase 1, 40 college health and office of disability staff members from public and private colleges/universities (90.0% female) completed a 41-question survey on their experiences with students who were YAS. In Phase 2, a one-hour educational in-service was provided to 18 health center medical providers (94.1% female) at a private university. In-service content was informed by the original survey. Providers completed pre- and post-test assessments of knowledge about late effects, knowledge of resources, and comfort with caring for YAS. Results: While most providers indicated that YAS are at risk of chronic health conditions because of their cancer treatment (70.6%), nearly all were unfamiliar with the published long-term follow-up guidelines for cancer survivorship (93.8%). Over half of providers did not have knowledge of cancer survivorship services in their area (58.8%). All respondents were interested in more survivorship education. Attendees of the in-service had higher knowledge of survivorship follow-up guidelines at the post-test assessment ( M=4.19) compared to the pre-test ( M=1.81), t=-5.56, p &lt; .001. They endorsed higher awareness of local resources at post-test ( M = 3.67) compared to the pre-test ( M=2.13), t=-3.62, p &lt; .01. Attendees reported higher comfort with caring for cancer survivors at post-test ( M=3.00) compared to the pre-test ( M=2.00), t=-3.42, p&lt; .01. Conclusions: College providers had little baseline knowledge of cancer survivorship guidelines, but were motivated to obtain more information. An in-service improved college health providers’ knowledge of caring for YAS, awareness of published guidelines, and comfort in providing care.

Recommendations for Premature Ovarian Insufficiency Surveillance for Female Survivors of Childhood, Adolescent, and Young Adult Cancer: A Report From the International Late Effects of Childhood Cancer Guideline Harmonization Group in Collaboration With the PanCareSurFup Consortium

Female survivors of childhood, adolescent, and young adult (CAYA) cancer who were treated with alkylating agents and/or radiation, with potential exposure of the ovaries, have an increased risk of premature ovarian insufficiency (POI). Clinical practice guidelines can facilitate these survivors' access to optimal treatment of late effects that may improve health and quality of survival; however, surveillance recommendations vary among the existing long-term follow-up guidelines, which impedes the implementation of screening. The present guideline was developed by using an evidence-based approach and summarizes harmonized POI surveillance recommendations for female survivors of CAYA cancer who were diagnosed at age < 25 years. The recommendations were formulated by an international multidisciplinary panel and graded according to the strength of the evidence and the potential benefit gained from early detection and intervention. The harmonized POI surveillance recommendations were developed by using a transparent process and are intended to facilitate care for survivors of CAYA cancer. The harmonized set of POI surveillance recommendations is intended to be scientifically rigorous, to positively influence health outcomes, and to facilitate the care for female survivors of CAYA cancer.