| Investigation |
Important aspects to screen for: |
| History |
General:
- Level of energy, general health
- Depression
- Social/employment situation
- Exercise
- Smoking, recreational drugs and alcohol ingestion
Chemotherapy related:
- Symptoms of cardiac dysfunction related to Adriamycin induced cardiomyopathy (e.g. shortness of breath on exertion, palpitations and orthopnoea)
- Problems with fertility related to alkylating agent exposure
- Symptoms of peripheral neuropathy related to Vincristine exposure
- Back pain, history of fractures - after intensive chemotherapy patients are more at risk for osteoporosis
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After mantle field RT (includes entire neck, supraclavicular regions, axillae and mediastinum):
- Dental problems xerostomia and TMJ dysfunction
- Respiratory symptoms such as shortness of breath, cough and chest pain
- Cardiac symptoms suggestive of ischemic heart disease ( e.g. angina type pain)
|
After abdominal and pelvic RT:
- Abdominal pain and cramping
- Frequent episodes of infection?
- Diarrhoea/constipation
- Change in bowel habit
- Problems with fertility - unable to conceive
- Women: menstrual cycle, menopausal symptoms, sexual function
- Men: sexual function
|
After splenectomy:
- Frequent episodes of infection?
- What vaccinations has the patient received?
|
| Examination |
General:
- Blood pressure
- Weight and height (Body Mass Index: BMI)
- General examination including palpation of all lymph node bearing areas to exclude recurrent disease
- Signs of congestive cardiac failure (related to Adriamycin exposure)
- Signs of pulmonary fibrosis (related to Bleomycin exposure)
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After mantle field RT:
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After abdominal and pelvic RT:
- Check for scoliosis as spinal growth may have been affected by RT
- Abdominal and pelvic examination
|
| Blood work |
General:
- Routine blood work including blood count, electrolytes, BUN, serum LDH and creatinine and liver function tests
|
After mantle field RT:
- Thyroid function tests (at least free T4 and TSH) because of the risk of hypothyroidism
|
| Radiology screening |
General HL: These investigations are done more frequently immediately after the end of therapy and then subsequently the timing is controversial:
- Investigations to exclude recurrent disease
- Intermittent chest X-ray
- PET scan: Usually not done routinely on survivors who are disease free for more than 10 years - as the PET itself is associated with radiation exposure and repeated investigation would lead to health risks
|
After mantle field RT:
- Ultrasound scan of the thyroid every 3 years to exclude papillary carcinoma of the thyroid
- Pulmonary function tests if indicated
- Early screening for breast cancer in female survivors with MR and mammography. COG recommend annual screening mammograms for women beginning 8 years after treatment or at age 25 years, whichever is later. MR screening also has a role for these high risk patients.
- Many years after mantle RT it is possible to develop carotid artery stenosis. Doppler ultrasound scan of the carotid arteries would be recommended every 2 - 3 years
|
After abdominal and pelvic RT:
- Ultrasound of the abdomen and pelvis every year or so may be helpful to exclude new masses
|
| Special investigations |
General:
- After any adriamycin exposure - echocardiogram every 2-3 years or so
|
Specialist
follow-up |
General:
- Most patients need to have other specialist physicians involved in their follow up with assessment every 1 - 2 years
- Anyone who has had intensive chemotherapy is at risk for early onset osteoporosis and should be seen in consultation by a specialist with expertise in this area roughly 10 years after the completion of therapy
- Alkylating chemotherapy alone (without RT) can cause infertility
|
After mantle field RT patients usually require follow up with:
- Endocrinology
- Oral oncology/dentistry
- Respirologist
|
After abdominal and pelvic RT:
- Fertility specialist
- Endocrinologist for hypogonadism
- Immunologist may be important if there is splenic dysfunction
|
After splenectomy:
|
| Supportive care |
- Family counselling
- Psychology
|
| Advice |
General: The patient should seek immediate medical help if a new swelling (painless or painful) appears within the previous RT field as this may be due to a second malignant neoplasm.
Lifestyle:
- Advise about diet, exercise and lifestyle choices. Smoking further increases the risk of second neoplasms (lung cancer), vascular and respiratory disease.
- Diet rich in Vitamin D, calcium and dairy servings to reduce risk of osteoporosis.
- Regular exercise is very important. Many previous HL patients will have been exposed to adriamycin and to be at risk for cardiomyopathy. Cardiac fitness is very important.
|
After mantle field RT:
- Meticulous dental care with regular cleaning and the use of fluoride.
- Early screening for breast cancer - increased risk of second cancers
- Skin previously in the RT field should be protected from the sun (more vulnerable to damage)
|
After abdominal and pelvic RT:
- Early screening for colon cancer if any abdominal RT of 30 Gy or higher to the abdomen, pelvis, or spine. Colonoscopy should be performed beginning at age 35 years or 10 years
following RT (whichever occurs last).
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After splenectomy:
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Patient information
(COG) Survivorship Guidelines |
General:
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After mantle RT:
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After abdominal and pelvic RT:
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