Main decision tree
Late effects: match the exposure
Key points
- The survivorship plan follows actual exposures: drug doses, radiation fields and doses, surgery and transplant.
- Anthracyclines (doxorubicin, daunorubicin): cardiomyopathy and heart failure, even below 450 mg/m²; lifelong echo surveillance.
- Chest radiation: early coronary artery disease and breast cancer.
- Neck radiation: hypothyroidism, nodules and thyroid cancer → yearly exam and TSH.
- Cisplatin: hearing loss → audiometry after therapy, then every 5 years.
- Cyclophosphamide: gonadal failure and infertility; offer fertility preservation counseling before treatment.
- Vincristine: peripheral and autonomic neuropathy (foot drop, constipation); never give it intrathecally.
Match follow-up to the exposure
A survivor's long-term screening plan depends on the treatment summary, not the cancer's name. Record each drug with its cumulative dose, each radiation field and dose, any surgery and any transplant.
The Children's Oncology Group Long-Term Follow-Up Guidelines turn these exposures into a lifelong screening schedule.
Anthracyclines and the heart
- Doxorubicin and daunorubicin (and mitoxantrone) can cause cardiomyopathy and heart failure years later.
- Risk rises with cumulative dose, younger age at treatment and chest radiation, but there is no fully safe dose; harm occurs below 450 mg/m².
- Survivors need echocardiogram surveillance for life, at an interval set by dose and radiation exposure.
Radiation late effects
| Radiation field | Late effects | Follow-up |
|---|---|---|
| Chest (heart in the field) | Premature coronary artery disease; breast cancer in females | Cardiac risk factor checks; early breast cancer screening |
| Cranial | Meningioma (dural-based mass with a dural tail), high-grade glioma, pituitary hormone loss | Neurologic review; endocrine testing |
| Neck (for example Hodgkin lymphoma) | Hypothyroidism, thyroid nodules, thyroid cancer | Yearly thyroid exam and TSH |
Alkylating agents and fertility
- Cyclophosphamide and other alkylators commonly cause gonadal dysfunction and infertility.
- They also raise the risk of a secondary AML.
- Offer fertility preservation counseling before treatment starts.
Cisplatin, bleomycin and vincristine
- Cisplatin: permanent high-frequency hearing loss; audiometry after therapy ends, then every 5 years.
- Bleomycin: lung fibrosis.
- Vincristine: neuropathy that can persist.
Vincristine toxicity during treatment
Vincristine damages microtubules in nerves. Foot drop and severe constipation during therapy point to peripheral and autonomic neuropathy.
- Peripheral neuropathy: foot drop, lost reflexes, jaw or limb pain.
- Autonomic neuropathy: constipation and ileus.
- SIADH with low sodium.
- Never give vincristine intrathecally: it is fatal.
Common questions
What are the late effects of doxorubicin?
Cardiomyopathy and heart failure, which can appear years later. Survivors need lifelong echocardiogram surveillance.
Which hearing test is needed after cisplatin?
Audiometry after therapy ends, then every 5 years.
What thyroid problems follow neck radiation?
Hypothyroidism, thyroid nodules and thyroid cancer. Check a thyroid exam and TSH every year.
Study this topic
Sources
- Children's Oncology Group Long-Term Follow-Up Guidelines
- IGHG 2023: Updated recommendations for cardiomyopathy surveillance in childhood cancer survivors (Lancet Oncol)
- NCI PDQ: Late effects of treatment for childhood cancer (health professional)
Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.