Appendix e-1

In 2003, the Children’s Oncology Group (COG) released risk-based, exposure-related guidelines, specifically designed to direct follow-up care for patients who were diagnosed and treated for pediatric malignancies.(1) The long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers represent a set of comprehensive screening recommendations that are clinically relevant and can be used to standardize and direct the follow-up care for this group of cancer survivors with specialized health care needs.

To ensure that the COG guidelines reflect the most current evidence-based recommendations supported by medical literature, multidisciplinary task forces have been organized within the COG Late Effects Committee to monitor the literature and recommend changes to the guidelines as new information becomes available. The Guideline Taskforce on Neurologic Complications performed an extensive review of the literature via Medline (National Library of Medicine, Bethesda, MD), encompassing the years 1985–2005.

For the purpose of this review, key words included “childhood cancer therapy,” “radiation,” “vasculopathy,” “stroke,” “carotid stenosis,” “brain tumor,” “vascular disease,” and “cerebral vascular disease.” References from the bibliographies of selected articles were used to broaden the search. The multidisciplinary task force used a modified version of the National Comprehensive Cancer Network Categories of Consensus system to score the guidelines.(2) Each score reflects the expert panel’s assessment of the strength of evidence from the literature linking cardiovascular disease to specific therapeutic exposures during childhood cancer, coupled with an assessment of the appropriateness of the screening recommendation based on the expert panel’s collective clinical experience.

“High-level evidence” was defined as evidence derived from high-quality case-control or cohort studies with adequate sample size and sufficient power to prove the hypothesis. “Lower-level evidence” was defined as evidence derived from nonanalytic studies, case reports, case series, and clinical experience.

The recommendations were scored based on the level of evidence as described in Table 1. Table 1. Categories of Consensus Scoring for the COG-LTFU Guidelines

Category Statement of Consensus 1 There is uniform consensus of the panel that: (1) there is high-level evidence linking the late effect with the therapeutic exposure and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members. 2A There is uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members. 2B There is non-uniform consensus of the panel that (1) there is lower-level evidence linking the late effect with the therapeutic exposure and (2) the screening recommendation is appropriate based on the collective clinical experience of panel members. 3 There is major disagreement that the recommendation is appropriate Uniform consensus: Near-unanimous agreement of the panel with some possible neutral positions. Non-uniform consensus: The majority of panel members agree with the recommendation; however, there is recognition among panel members that, given the quality of evidence, clinicians may choose to adopt different approaches. High-level evidence: Evidence derived from high quality case control or cohort studies. Lower-level evidence: Evidence derived from non-analytic studies, case reports, case series, and clinical experience.

References

1. Landier W, Bhatia S, Eshelman DA, et al. Development of risk-based guidelines for pediatric cancer survivors: the Children's Oncology Group Long-Term Follow-Up Guidelines from the Children's Oncology Group Late Effects Committee and Nursing Discipline. J Clin Oncol 2004;22:4979-4990. 2. Winn RJ, Botnick WZ. The NCCN Guideline Program: a conceptual framework. Oncology (Williston Park) 1997;11:25-32.