OncoLife Care Plan

The oncology team should provide a monitoring plan. Typical monitoring includes:

• Periodic physical exams by a healthcare provider.
• CT scans and x-rays may be done periodically, or if symptoms arise. 
• Blood work when new symptoms arise 

The recommended follow up care for patients with ALL includes:

• Periodic complete blood count (CBC) and bone marrow biopsy / aspirate if these results are abnormal.
• Other tests as needed, including liver function tests, cerebrospinal fluid testing and cardiac testing.
• Physical exam, every 1-2 months for the first year after completing chemotherapy, every 3 months for the second year and every 6 months thereafter.

General recommendations for ALL follow-up care state that survivors should be monitored with:

• Have a complete blood count (CBC) checked every 1-3 months for 2 years, then every 3-6 months for up to 5 years.
• A bone marrow biopsy / aspirate is only necessary if these results are abnormal.

General recommendations for follow up care include: 

• History and physical examination by their physician every 3 months for two years. This visit should include a digital rectal exam, anoscopy, and evaluation of the lymph nodes in the groin area. 
• CT scan of the chest, abdomen and pelvis and lab tests may be used to monitor for recurrence in higher risk disease. 

There are no formal guidelines for follow up care; therefore, the oncology team should provide a monitoring plan. Typical monitoring includes:

• Periodic physical exams by a physician.
• Abdominal CT scan every 6 months for 3-5 years, then at the discretion of the oncology team.
• Tumor markers may be evaluated every 3-6 months if they were initially elevated at the time of diagnosis (these can include CEA, CA-125 and CA 19-9).

The recommended follow-up care for patients with bladder cancer according to the stage and grade of the cancer are as follows:

• Non invasive, low grade tumors (Ta, low grade):
  • Cystoscopy every 3 months initially, with increasing intervals as deemed appropriate.
• Early stage tumors (Ta - high grade, T1 – low and high grade):
  • Cystoscopy with urine cytology every 3-6 months for 2 years, then increasing intervals as appropriate. The physician may choose to check urinary tumor markers.
  • Consider radiology tests (CT, MRI) every 1-2 years for high-grade tumors.
• Muscle invasive tumors treated with the intent to cure:
  • Laboratory testing (urine cytology, liver function, electrolytes, and creatinine) and chest x-ray every 6-12 months.
  • Radiologic imaging (CT, IVP, ultrasound, etc.) of the upper urinary tracts, abdomen and pelvis every 3-6 months for 2 years, then as indicated.
  • If bladder-sparing surgery: cystoscopy with cytology every 3-6 months for 2 years, then at increased intervals as deemed appropriate.
• Follow up after cystectomy:
  • Laboratory work (urine cytology, creatinine and electrolytes) every 3-6 months for 2 years, then as indicated.
  • Imaging (CT, MRI) of the chest, abdomen and pelvis every 3 to 12 months for 2 years (based on recurrence risk), then as indicated.
  • Urethral washings cytology every 6-12 months.
  • If the surgery was a partial cystectomy, follow up should also include cystoscopy every 3-6 months for 2 years, then at increasing intervals to monitor for relapse in the bladder.

There are a number of different types of brain tumors, each with its own treatment and follow up recommendations. The following are general recommendations:

• Physical exam and brain MRI every 2-6 months (depending on tumor type) for 2-3 years, then every 6-12 months (also determined by tumor type).
• Assess for any neurological changes, concerning symptoms of recurrence, and depression (higher risk in this population).
• Discuss the possibility of seizures and the need for anti-seizure medication. If seizures are a concern, discuss safety implications, including their ability to operate a vehicle.

The following are recommended for follow care after treatment for breast cancer:

• Mammogram annually for those who have had a single mastectomy or lumpectomy Educate patients about possible symptoms of recurrences including new any changes, lumps, swelling or skin rashes to your physician.
• Be seen and examined by your oncologist every 3-6 months for 3 years, then every 6-12 months for the next two years and then annually.
• Women with an intact uterus on tamoxifen should see a gynecologist annually and notify their physician of any vaginal bleeding.
• Women taking aromatase inhibitors whose menstrual cycles have stopped should have a Dexa scan as a baseline, then periodically.
• Consider referral to genetic counseling if family or personal history includes early age at diagnosis of breast cancer (<50), triple negative disease, multiple primary cancers, or a family history of breast or ovarian cancer.
• Evidence has shown that leading an active lifestyle and maintaining a healthy weight (body mass index of 20-25), may lead to improved breast cancer outcomes.
• Any new, unusual and/or persistent symptoms should be brought to the attention of your care team.

After treatment for cervical cancer, the following are recommended for follow-up care by the Society for Gynecologic Oncology:

• Physical and pelvic exams every 3-6 months for 2 years, then every 6 mos – 1 year in years 2-5, and then annually after treatment.
• Annual Pap testing of cervical/vaginal tissue
• Routine labs and radiologic exams are not recommended unless patient exhibits signs of recurrence including vaginal bleeding, weight loss, abdominal pain and fatigue.
• If recurrence is suspected, CT +/- PET scan are recommended
• After radiation, patients should receive education regarding use of vaginal dilators to prevent losing vaginal elasticity and the formation of scar tissue while improving quality of life and maintaining sexual function after treatment.
• Provide education to patient regarding maintaining healthy lifestyle, smoking cessation, weight management, exercise and life after cancer.

The guidelines for CLL follow up care depend on what therapies the patient has received and if they will continue to have treatments. The oncology team should provide follow up information for this patient.

The recommendations for CML follow up care depend on what therapies the patient has received and where they are in treatment. General recommendations include:

• Patients who are taking a tyrosine kinase inhibitor will be monitored for a complete cytogenetic response at 3, 6, 12 and 18 months. Once a response is detected, BCR-ABL levels are typically measured every 3-6 months. 
• Patients who have undergone allogeneic transplant are typically monitored every 3 months for 2 years, then every 6 months for 3 years.  
• Any new symptom should be brought to the attention of the provider. 

The general guidelines recommended for follow up care for colon cancer patients are based on stage and include:

Early stage:

• Survivors should undergo colonoscopy one year after surgery.
  • If advanced adenoma is present, repeat in 1 year.
  • If no advanced adenoma, repeat in 3 years, then every 5 years.
• Any new, unusual and/or persistent symptoms should be brought to the attention of your care team.

More advanced stage:

• Be seen and examined by their physician every 3-6 months for two years, then every 6 months for a total of 5 years.
• The tumor marker CEA should be checked at these visits.
• Survivors should undergo colonoscopy one year after surgery (this should be done in 3-6 months if no colonoscopy was performed before surgery).
  • If advanced adenoma is present, repeat in 1 year.
  • If no advanced adenoma, repeat in 3 years, then every 5 years.
• Annual CT scan for up to 5 years after diagnosis for survivors at high risk for recurrence. Stage IV survivors will have more frequent CT scans; every 3-6 months for 2 years, then every 6-12 months for up to 3 more years.

HCP Treatment Information:

After treatment for endometrial (uterine) cancer, the following are recommended for follow-up care:

• Physical exam, including pelvic examination, every 3-6 months for the first year after treatment.
• In subsequent years, physical examination should occur every 6 months until 5 years post treatment.  In patients with low risk, stage IA/grade 1 or 2 disease this exam can occur annually in years 2-5.
• Routine labs and radiologic exams are not recommended unless patient exhibits signs of recurrence including vaginal bleeding, weight loss, abdominal pain and fatigue.
• If recurrent is suspected, CT or PET +/- CA 125 testing is indicated.
• Patients should receive education regarding use of vaginal dilators to prevent losing vaginal elasticity and the formation of scar tissue while improving quality of life and maintaining sexual function after treatment.
• Consider genetic testing in patients with uterine cancer under the age of 50 or in those with family history of cancer associated with Lynch Syndrome.
• Provide education to patient regarding maintaining healthy lifestyle, smoking cessation, weight management, exercise and life after cancer.

The general recommendations for follow up after treatment for esophageal cancer include:

• Physical exam every 3-6 months for 1-2 years, then every 6-12 months for years 3-5, then annually thereafter.
• Blood work when new symptoms arise or there are problems maintaining adequate nutrition.
• Endoscopy and imaging studies should be obtained as recommended by the oncologist, as these are based on stage, risk, and the cancer treatment received.  

 General recommended follow up care for patients with cancer of the fallopian tube includes:

• Oncology visit every 2-4 months for 2 years, then every 3-6 months for 3 years, then annually after 5 years. Each visit should include:
  • Physical exam with pelvic exam.
  • Ca-125 level (or other tumor marker level, if these were elevated at initial diagnosis).
  • Radiology testing (X-ray, MRI, CT or PET scan) may be done if there are concerning symptoms.

The general recommendations for follow up care for patients with gallbladder cancer include:

• The healthcare provider may consider imaging (CT scan, MRI) every 6 months for 2 year

The following are general recommendations from the American Cancer Society for survivors of head and neck cancer:

• Physical exam every 1-3 months for year 1, then every 2-6 months for year 2, then every 4-8 months for years 3-5, then every 12 months thereafter.
• Post-treatment baseline imaging of the primary site is recommended within 6 months of completing treatment. Further imaging should be conducted if there are concerning symptom, but is not needed routinely.
• If the neck was in the radiation treatment field, thyroid stimulating hormone (TSH) levels should be checked every 6-12 months.
• If patient experiences spinal accessory nerve palsy(SAN), neck spasms (cervical dystonia), shoulder dysfunction, or lymphedema, referral to rehab specialist.
• If challenges with speech and swallowing persist, ongoing management with speech-language pathology. These issues can arise many years after treatment due to scarring and radiation damage.
• Consider medications for pain management and spasm control associated with cervical dystonia.
• If the patient continues to smoke or use alcohol, they should be referred to a cessation or counseling program to help them quit.
• Former smokers may be eligible for lung cancer screening.
• If the mouth was in the treatment field, they should have routine dental evaluations and perform regular mouth care, including fluoride, brushing and dietary restrictions to help prevent and identify any long-term damage early. 
• Referral for speech, hearing and swallowing rehabilitation and/or nutritional counseling if needed.

Follow up after treatment, up to 5 years:

• Physical exam every 3-6 months for 1-2yrs, then every 6-12 months until year 3, then annually.
• Annual flu vaccine.
• Annual thyroid stimulating hormone (TSH) level if radiation field included the neck.
• Some survivors may have a CT scan within the first year after treatment. Otherwise, bloodwork and radiology studies are performed as needed, based on symptoms.

Follow up after 5 years:

There has been a considerable amount of research done in Hodgkin’s lymphoma survivors and, as a result, guidelines for monitoring for late effects in these survivors have been developed. The American Cancer Society recommendations include:

• Physical exam annually. Continued follow up is important to monitor for late effects.
• Check blood pressure annually. Aggressive management of cardiovascular risk factors, such as hypertension, elevated cholesterol, and elevated triglycerides, as cardiac disease can develop at a young age.
• Annual flu vaccine.
• Patients who had a splenectomy or radiation to the spleen should be re-vaccinated with pneumococcal, meningococcal and Haemophilus influenza type b (Hib) vaccines and follow recommendations for a non-functioning spleen.
• Due to cardiac risk, provider may consider a stress test / echocardiogram every 10 years. If radiation field included the neck, consider an ultrasound of the neck veins every 10 years.
• Laboratory studies, including complete blood count and chemistry profile annually. Annual thyroid stimulating hormone (TSH) level for survivors who received radiation therapy that included the neck. Lipid (cholesterol) levels should be checked twice a year.
• Annual chest x-ray or chest CT for patients who are at increased risk for developing lung cancer due to prior therapy, including alkylating agent chemotherapy (typically Cytoxan [cyclophosphamide]), radiation to the chest, or heavy smoking.
• Breast cancer screening is recommended for women who received radiation to the chest or axilla (armpit). This includes:
  • Annual breast exam by a healthcare professional, and monthly self-breast exam.
  • Begin annual mammograms 8-10 years post therapy, or at age 40, whichever is earlier.
  • Breast MRI, in addition to the annual mammogram, for women who had chest irradiation between the ages of 10 and 30 years.

The recommended follow up care for patients with kidney cancer includes:

• A physical exam and blood work (comprehensive metabolic panel) every 3-6 months for 2 years, then annually for 5 years.
• Radiologic testing may include: chest and abdominal CT scan, MRI, abdominal/renal ultrasound, and chest x-ray. The test and frequency are dependent on the treatment received and the stage of the cancer.

The recommended follow up care for patients with liver cancer includes:

• Radiologic imaging every 3-6 months for 2 years, then annually.
• Alpha fetal protein (AFP) level (if initially elevated) every 3 months for 2 years, then every 6 months.

The follow up care recommendations for patients with lung cancer include:

• For Non-small cell lung cancer:
  • Physical exam and chest CT every 6-12 months for 2 years, then annually.
• For Small cell lung cancer:
  • Physical exam and chest CT every 3-4 months for years 1 and 2, then every 6 months for years 3 through 5, then annually thereafter.
• If the patient is a smoker, provide smoking cessation advice, pharmacotherapy and counseling referrals.
• Annual flu vaccine and vaccination for herpes zoster (shingles) and pneumococcal pneumonia.
• Any new pulmonary nodules discovered on imaging should be worked up as a potential new primary.

General recommendations for follow up care of melanoma are stage dependent and include:

• All survivors should have annual skin exam by a healthcare provider for life. Regular skin and lymph node self-exams, reporting any changes to your provider.
• All survivors should receive education regarding new, unusual or persistent symptoms to report to their care team as well as sun safety, skin protection and performing skin self-exams.

Stages IIB-IV: 

• • A complete skin exam at least once a year.
  • The patient should be educated to perform a self-skin and lymph node exam monthly.
  • History and physical exam every 3-6 months for 2 years, then every 3-12 months for 3 years, then annually.
  • In the first 3-5 years, it is reasonable to perform chest x-ray, CT or PET scan and brain MRI to screen for metastatic disease in patients with high-risk disease. Radiologic screening is not recommended after 3-5 years.

Stages IA-IIA:

• • A complete skin exam at least once a year.
  • The patient should be educated to perform a self-skin and lymph node exam monthly.
  • History and physical exam every 3-12 months for 5 years, then annually.
  • Routine radiologic imaging is not recommended in asymptomatic patients.

There are no formal recommendations for follow up care in mesothelioma; therefore, the oncology team should provide a monitoring plan. Typical monitoring includes:

• Physical exam and chest CT scan every 3 months for 2-3 years, then every 6 months until year 5, then annually thereafter.

General follow up recommendations:

• Periodic physical exam monthly during initial treatment, then every 2-3 months during maintenance and observation
• Laboratory testing:
  • Quantitative immunoglobulins & quantitation of M protein at least every 3 months.
  • Complete blood count with differential, BUN, creatinine and calcium.
  • A bone marrow biopsy and serum free light chain assay are only needed if symptoms arise.
  • Radiologic testing:
    • Annual bone survey or more often if symptoms present.
    • Other radiology tests (MRI, PET) if symptoms arise.

There are no formal guidelines for MDS follow up care, however, typical monitoring includes:

• Periodic complete blood count (CBC) and bone marrow biopsy / aspirate if these results are abnormal.

There are some 40 different types of non-Hodgkin’s lymphomas, each with its own treatment and follow up recommendations.  Guidelines for follow up care recommendations based on this patient’s specific tumor type. 

Educate your patients to report any new, unusual and/or persistent symptoms that should be brought to the attention of the care team.

The general recommended follow up care for patients with non-melanoma skin cancer include:

• Basal cell cancers:
  • Skin examination every 6-12 months for life.
  • Patient should receive education regarding sun safety, skin protection and performing skin self-exams.
• Squamous cell cancers:
  • Local, resected tumor: physical exam every 3-12 months for 2 years, then every 6-12 months for 3 years, than annually.
  • Tumor with spread to lymph node: physical exam every 1-3 months for year 1, every 2-4 months for year 2, every 4-6 months for 3 years, then every 6-12 months for life.
  • Patient should receive education regarding sun safety, skin protection and performing skin self-exams.

The Society for Gynecologic Oncology recommends the following post treatment care for patients with ovarian or primary peritoneal cancer:

• Oncology visit every 2-4 months for 2 years, then every 3-6 months for 3 years, then annually after 5 years. Each visit should include:
  • Physical exam with pelvic exam.
  • Ca-125 level (or other tumor marker level, if these were elevated at initial diagnosis), with other blood work as indicated.
  • Radiology testing (X-ray, MRI, CT or PET scan) may be done if there are concerning symptoms.
  • Consider referral to genetic counseling if the patient has a family or personal history including early age at diagnosis (<50) of breast or ovarian cancer, triple negative breast cancer, multiple primary cancers, or a family history of breast or ovarian cancer.

The recommendations for follow up care for patients with pancreatic cancer include:

• Physical examination every 3-6 months for 2 years, then annually.
• CA19-9 blood test (tumor marker test) and CT scan may also be done every 3-6 months for 2 years and then annually.     

Follow up care for penile cancer depends on the stage at diagnosis and the treatment received. General recommendations for follow up care after penile cancer include:

• Exams every 3-6 months for the first 2 years, then every 6-12 months thereafter. These should include a thorough examination of the penis and groin area.
• The patient should examine their penis and groin area routinely and report any changes.
• In general, CT scans and chest x-rays are done periodically in men who had lymph node involvement, or if symptoms arise in any survivor.

The recommendations for follow up care for patients with prostate cancer include:Follow

• For men on active surveillance/observation:
  • PSA (prostate specific antigen) every 6 months.
  • Digital rectal exam (DRE) every 12 months, which should be taken after the PSA blood specimen, as DRE can affect the PSA result.
  • Periodic repeat biopsies to evaluate whether the tumor’s aggressiveness is changing. For men on active surveillance, this is usually performed one year after the initial prostate needle biopsy, and then annually.
• For men who have been treated with surgery and/or radiation therapy, post treatment surveillance includes:
  • PSA every 6-12 months for the first 5 years, then annually.
  • Digital rectal exam (DRE) every year, which should be taken after the PSA blood specimen, as DRE can affect the PSA result.
• Survivors who have locally advanced or metastatic disease should have a physical exam and PSA every 3-6 months.

The general recommendations for follow up care for patients with rectal cancer include:

• History and physical examination every 3-6 months for two years, then every 6 months for a total of 5 years.
• The tumor marker CEA should be checked at these visits for survivors who had tumors that were at least stage T2 at diagnosis.
• Survivors should undergo colonoscopy one year after surgery. If no colonoscopy was performed before surgery, this should be done in 3-6 months.
  • If advanced adenoma is present, repeat in 1 year.
  • If no advanced adenoma, repeat in 3 years, then every 5 years.
• Survivors at high risk of recurrence may be followed with an annual CT scan for 3 years after diagnosis.
• If the woman has received radiation therapy, she should use a vaginal dilator regularly to prevent the vaginal tissue from losing elasticity and forming scar tissue, which can make intercourse or vaginal exams painful. This is important both for improving quality of life, and for improving the ability to follow your cancer after treatment for evidence of recurrence.

Follow up recommendations vary slightly according to the histologic diagnosis and the grade of the lesion. However, in general, these recommendations include:

• A physical exam, chest imaging and imaging of the local tumor area every 2-6 months (depending on the type of sarcoma) for the first 5 years, then annually thereafter.
• Other blood work and imaging tests are ordered based on symptoms.
• Assessment of function and referral for rehabilitative therapy when needed.

The recommendations for follow up care after stomach cancer include:

• Physical exam every 3-6 months for 1-2 years, then every 6-12 months for 3-5 years, then annually.
• Radiology and laboratory tests and endoscopy are done if concerning symptoms develop.
• Patients who have had surgical removal of the stomach need to be monitored and treated for vitamin B12 and iron deficiency.

Guidelines for specific oncology follow up care are available on the Testicular Cancer Resource Center website (TCRC). This varies based on the type of testicular cancer (seminoma versus non-seminoma), the stage of the disease, and the treatment received, but generally includes:

• Physical exam, tumor markers, abdominal CT scan and/or chest x-ray.
• Monitoring for hyperlipidemia and hypertension annually, unless more frequent monitoring and treatment indicated is indicated based on health history.
• Monitoring for metabolic syndrome, as these survivors are at higher risk. 

General recommendations for follow up care after thymoma/thymic carcinoma include:

• Periodic physical exams, which should continue for at least 10 years due to the risk of late recurrence of these cancers.
• Chest CT scan every 6 months for 2 years, then annually for 5 years for thymic carcinoma and annually for 10 years for thymoma.

The follow up care recommendations for thyroid cancer follow up care vary slightly depending on the tumor type, stage and treatment received, but in general include:

• A physical exam (including neck examination) and TSH, thyroglobulin and antithyroglobulin antibody levels at 6 and 12 months, then annually if the patient remains disease free.
• Periodic neck ultrasound.
• Some survivors will require imaging (radioiodine or non-radioiodine), depending on their initial staging and previous imaging results.

There are no formal recommendations for vaginal or vulvar cancer follow up care; however, typical monitoring includes:

• Frequent exams for the first 5 years, then every 6-12 months thereafter. These should include a pelvic exam and Pap smear.
• CT scans and chest x-rays may be done periodically, or if symptoms arise.