Clinical Practice Guidelines

Eleanor Hendershot is an experienced pediatric oncology nurse at McMaster Children’s Hospital, whose career spans over 30 years, including roles at SickKids and Princess Margaret Cancer Centre. She is deeply focused on survivorship and AfterCare and is a dedicated advocate for evidence-based compassionate follow-up care for childhood cancer survivors.

In reflecting on my last three decades working in pediatric oncology nursing, it’s evident that the field has undergone remarkable transformation. In particular, with my focus on AfterCare for the past 13 years, with experience across leading institutions, I’ve witnessed how advances in therapy, supportive care, and clinical research have significantly improved outcomes.

The majority of children are not only surviving cancer but also living long and productive lives. This progress has shifted attention toward survivorship, with increasing emphasis on the long-term health and well-being of pediatric cancer survivors.

Within survivorship care, the Children’s Oncology Group has developed evidence-based guidelines (www.survivorshipguidelines.org) to support routine screening for late effects of cancer and its treatment. These late effects are influenced by the type of disease and individual treatment exposures (chemotherapy, radiotherapy, surgery), and may include second malignancies, organ dysfunction (cardiovascular, auditory, bony, renal, pulmonary, endocrine, neurocognitive, etc.), and psychosocial concerns. Importantly, late effects may emerge years or even decades after therapy ends, making survivorship care an essential component of comprehensive oncology practice.

One of the most significant recent advances in this field is the refinement of late-effects screening based on new evidence, research and expert consensus. A key example is the monitoring of cardiomyopathy (disease of the heart muscle) in survivors treated with anthracyclines (a type of chemotherapy used to treat certain types of cancer such as leukemia and lymphoma). Until recently, guidelines recommended lifelong echocardiograms for all survivors, regardless of cumulative anthracycline dose. New evidence, however, has demonstrated that survivors who received less than 100 mg/m² are not at increased risk of cardiomyopathy and therefore do not require lifelong routine echocardiographic surveillance.

Although this adjustment may appear modest, its impact is profound. Survivors of leukemia, the largest survivor population, typically receive low cumulative anthracycline doses. For these patients and their families, lifelong counselling and repeated cardiac screening created unnecessary anxiety and reinforced the sense of living under ongoing medical surveillance. From a cost-benefit perspective, routine echocardiography in low-risk patients carried significant cost and resource implications without measurable benefit.

As part of the updated guidelines, ongoing heart monitoring is no longer required, allowing leukemia survivors, in some instances, to be discharged from follow-up care once they are ten years post-therapy and have reached the age of 18 or if they are a teenager when diagnosed until both criteria are met.

The benefits of this targeted approach extend well beyond medical outcomes. By reducing unnecessary tests and clinic visits, survivors and families gain greater peace of mind and some relief from the intensity of lifelong surveillance, while healthcare systems benefit from more efficient use of resources. Just as importantly, minimizing disruptions to education, employment, and social development allows survivors to move forward in their lives with greater confidence. This balance—protecting long-term health while recognizing that not all survivors carry the same risks—has become central to modern, individualized survivorship care.

In reflecting on the evolution of pediatric oncology nursing and survivorship care, it’s clear that our field has made tremendous strides—not only in improving survival rates but also in refining how we support survivors long-term. The shift toward individualized care, such as updated cardiac screening guidelines, has reduced unnecessary interventions and empowered survivors to live with greater confidence.

Since 2001, POGO has been a cornerstone in supporting survivors of childhood cancer through its AfterCare Clinic Program network. Today, eight POGO AfterCare Clinics across Ontario serve more than 5,000 survivors, helping ensure that children, adolescents and young adult survivors of childhood cancer receive the essential follow-up care they need to lead healthy, fulfilling lives.

This contribution to “Reflective Practice Corner” was written for the fall 2025 issue of the RePORTer by Eleanor Hendershot, MN, BScN, RN, Pediatric Nurse Practitioner, McMaster Children’s Hospital.

Reflective Practice Corner, a standing section in The RePORTer—POGO’s Nursing Newsletter—features reflections from nurses across the province, offering insight into their experiences. It also invites readers to pause and consider the questions posed.