Clinical approach

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Late Effects

Clinical Approach



Survivors of childhood cancer have different long-term health risks depending on many factors such as the type of their previous cancer, how old they were when they were treated and what treatment they received.

Clinically it is very important to establish exactly the details of their original diagnosis and therapy, in order to assess relevant long term health problems.


In the history is important to ask questions about the:

Original diagnosis:

  • How old were you when you developed cancer?
  • What type of cancer was this?
  • Where did the cancer start and what adjacent organs did it affect?
  • Had it spread to other distant organs?


  • Surgery(s):
    • Date
    • Extent and organs removed (important to establish if this involved organs like the spleen or kidneys)
    • Complications after surgery
  • Radiation therapy:
    • Age at the time of RT
    • Region of the body treated
    • Start date and finish date
    • Total dose and fractionation (how many treatments was it split up into)
    • Side effects at the time or soon after
  • Chemotherapy:
    • Start and finish date
    • What drugs were used?
    • Total dose of each drug (for some drugs such as Adriamycin and cyclophosphamide this is very important)
    • Any other systemic therapy given?
  • Was there any other serious health issue prior to, at time of or immediately after therapy? For example:
    • Infection (meningitis, typhlitis)
    • Blocked shunt

Current Health Status:

  • General Health:
    • Energy level and fatigue
    • Weight - steady, gained, loss
    • Appetite
  • Activities of daily living
    • Exercise - how much and how frequently
  • Habits - smoking, alcohol consumption, recreational drugs
  • Fertility
    • Menstrual cycle regular in woman?
    • Trying to conceive?
    • Any previous testing to determine fertility status?
  • Education history:
    • Any problems in high school?
    • Did they complete grade 12?
    • Did they obtain a special high school diploma?
      • In BC, students may obtain a grade 12 "Dogwood diploma" which can involve completion of a course in basic living skills.
    • Any post-secondary education?
  • Employment:
    • How long?
    • Any benefits?
    • Is it possible to afford the medications you need?
    • Happy with work?
  • Mental health
    • Any depression  or anxiety?
    • Social life and relationships?
  • Review of systems with attention to organs that were treated previously. For example:
    • RT to gut may be associated with long term malabsorption and diarrhoea
    • Previous anthracycline therapy may be associated with symptoms of cardiac failure such as shortness of breath on exertion and difficulty lying flat
    • Previous treatment for a brain tumor may cause:
      • poor short term memory
      • difficulty concentrating
      • seizures
      • visual problems
      • hearing impairment



Always check weight and height (so BMI can be calculated) and blood pressure.

Hypertension is a common problem in survivors of childhood cancer

General examination:

  • General physical examination
  • To specifically look for physical problems related to previous treatment:

Examples of focussed examination:

Therapy Examination What you are looking for
RT to anywhere to at all in the head and neck Thyroid

Benign nodules


Thyroid cancer

RT to face and jaw Teeth

Dental caries





RT to face close to eyes Eye - cranial nerve examination and fundoscopy

Visual deficits




Cranial nerve palsy


Optic atrophy


RT to spine or one side of the abdomen

Assess if spine is straight:

  • Assess for asymmetry while touching toes
  • Spine may be short with reduced sitting height
RT to mediastinum Cardiac examination

Valvular disease




Chronic pericarditis


Ischemic heart disease

Breast examination Breast cancer
RT to lungs Respiratory examination Pulmonary fibrosis
Chest wall deformity
Adriamycin chemotherapy Cardiac examination Cardiomyopathy
Bleomycin chemotherapy Respiratory examination Pulmonary fibrosis
Platinum chemotherapy Blood pressure and renal examination Renal dysfunction
Vincristine chemotherapy Neurological examination Peripheral neuropathy


Screening Investigations:

Screening investigations depend very much on the previous diagnosis and therapy.  Rough guidelines are given in the different sections of this website.  These investigations are not "set in stone" and recommendations continuously change. There is also controversy about the frequency and efficacy of these tests. Much emphasis is placed on "evidence based" screening recommendations in a field where we are just beginning to appreciate the extent of these problems.

Link: Children's Oncology Group long-term follow up guidelines for survivors of childhood and adolescent cancers


Depending on the risk of late effects after therapy, it may be important to involve a multidisciplinary health care team in the investigation and follow up of these patients. 

Survivor's health problems may be broad ranging and severe.  For example, a brain tumor survivor may need a neurologist (seizures), an endocrinologist (pituitary and thyroid deficiency), an ophthalmologist (visual problems), a psychiatrist/psychologist for depression and neurocognitive difficulties, a rehabilitation medicine team to provide help with vocational and recreational rehabilitation and a social worker to provide practical assistance.


The Children's Oncology Group (COG) have ongoing research programs to identify the different factors which increase the risk of late effects:



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