| name | es-ghd-screening-indication |
| description | This skill identifies childhood cancer survivors who require lifelong periodic assessment for growth hormone deficiency based on hypothalamic-pituitary tumor history or cranial/spinal radiation exposure ≥18 Gy. It is triggered by questions such as "Does this survivor need GHD screening?" or "Is this patient at risk for growth hormone deficiency post-radiation?" |
Screen for GHD indication in childhood cancer survivors
STEP 1 — Gather Information
Collect history of hypothalamic–pituitary axis tumors (e.g., suprasellar, optic pathway) or surgery, and details of radiation therapy: fields (cranial, craniospinal, total body), dose per fraction and total dose, age at exposure. Also obtain baseline height and growth velocity if available.
Proceed to assess eligibility for GHD screening.
STEP 2 — Rule In / Rule Out
If the survivor has a history of HP axis tumor/surgery OR received HP axis radiation ≥18 Gy (total dose), then rule in for lifelong periodic GHD assessment; otherwise rule out (no routine GHD screening indicated per this guideline).
Decision: rule in or rule out for GHD screening.
STEP 3 — Classify or Stratify
For those ruled in, stratify by age at exposure: if exposed before puberty, assess height every 6 months; if exposed during or after puberty, assess every 12 months (based on technical remark to assess height every 6 to 12 months).
Decision: set assessment interval.
STEP 4 — Decide
Implement lifelong periodic clinical assessment: measure standing height (and sitting height if spinal radiation) at the determined interval, plot growth velocity, and refer for provocative GH testing if growth deceleration (>0.5 SD/year) or other signs of GHD appear.
Action: initiate periodic height monitoring and trigger testing as needed.
Clinical Guardrails / Mimics / Pitfalls
Do not rely solely on serum IGF-I levels to rule out GHD; avoid spontaneous GH sampling; do not omit assessment in survivors with spinal radiation due to risk of disproportionate growth; do not delay assessment until symptomatic; do not assume normal IGF-I excludes GHD in obese or pubertal patients where IGF-I may be misleading.
Concrete Clinical Example
A 16-year-old survivor of medulloblastoma treated with craniospinal irradiation 24 Gy at age 5 asks, "Do I need GHD screening?" History shows HP axis radiation ≥18 Gy, so rule in. Age at exposure < puberty, so assess height every 6 months. Over the next year, height velocity drops from 5 cm/year to 2 cm/year; provocative testing (insulin tolerance test) confirms GHD, leading to initiation of GH therapy.
Source: Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, doi:10.1210/jc.2018-01175
TODO: consider adding scripts/calc.py for the es-ghd-screening-indication calculator
