@erosolaraijs/cure 2.3.0 → 2.4.0

package/src/capabilities/survivorshipManagement.ts

@@ -0,0 +1,1213 @@
+/**
+ * Comprehensive Cancer Survivorship and Late Effects Management
+ *
+ * ╔═══════════════════════════════════════════════════════════════════════════════╗
+ * ║  SURVIVORSHIP CARE - ENSURING CURE AND QUALITY OF LIFE                       ║
+ * ╠═══════════════════════════════════════════════════════════════════════════════╣
+ * ║  This module provides:                                                        ║
+ * ║  - Surveillance protocols for recurrence detection                           ║
+ * ║  - Late effects screening and management                                     ║
+ * ║  - Secondary malignancy prevention                                           ║
+ * ║  - Psychosocial support frameworks                                           ║
+ * ║  - Fertility and family planning guidance                                    ║
+ * ║  - Rehabilitation and quality of life optimization                           ║
+ * ╚═══════════════════════════════════════════════════════════════════════════════╝
+ */
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// SURVIVORSHIP DEFINITIONS
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export interface SurvivorshipCareplan {
+  cancerType: string;
+  stage: string;
+  treatmentReceived: TreatmentSummary;
+  surveillanceProtocol: SurveillanceProtocol;
+  lateEffectsScreening: LateEffectsScreening[];
+  secondaryMalignancyScreening: SecondaryMalignancyScreen[];
+  psychosocialSupport: PsychosocialPlan;
+  rehabilitationNeeds: RehabilitationPlan;
+  healthMaintenanceRecommendations: HealthMaintenance[];
+}
+
+export interface TreatmentSummary {
+  surgery: SurgicalSummary[];
+  radiation: RadiationSummary[];
+  systemicTherapy: SystemicTherapySummary[];
+  transplant?: TransplantSummary;
+  otherTreatments: string[];
+}
+
+export interface SurgicalSummary {
+  procedure: string;
+  date: string;
+  findings: string;
+  complications: string[];
+  longTermConsiderations: string[];
+}
+
+export interface RadiationSummary {
+  site: string;
+  modality: 'EBRT' | 'IMRT' | 'SBRT' | 'Proton' | 'Brachytherapy' | 'TBI';
+  totalDose: string;
+  fractions: number;
+  completionDate: string;
+  acuteToxicities: string[];
+  expectedLateEffects: string[];
+}
+
+export interface SystemicTherapySummary {
+  agentClass: string;
+  specificAgents: string[];
+  cumulativeDoses?: Record<string, string>;
+  duration: string;
+  completionDate: string;
+  significantToxicities: string[];
+  expectedLateEffects: string[];
+}
+
+export interface TransplantSummary {
+  type: 'Autologous' | 'Allogeneic';
+  source: 'Bone Marrow' | 'PBSC' | 'Cord Blood';
+  date: string;
+  conditioning: string;
+  gvhdHistory?: string;
+  immuneReconstitution: string;
+}
+
+export interface SurveillanceProtocol {
+  recurrenceRisk: 'Low' | 'Intermediate' | 'High';
+  duration: string;
+  visits: SurveillanceVisit[];
+  discontinuationCriteria: string[];
+}
+
+export interface SurveillanceVisit {
+  timing: string;
+  components: SurveillanceComponent[];
+  purpose: string;
+}
+
+export interface SurveillanceComponent {
+  type: 'History/Physical' | 'Laboratory' | 'Imaging' | 'Endoscopy' | 'Biomarker';
+  specific: string;
+  frequency: string;
+  rationale: string;
+}
+
+export interface LateEffectsScreening {
+  system: OrganSystem;
+  risks: LateEffectRisk[];
+  screeningProtocol: ScreeningItem[];
+  managementGuidance: ManagementGuideline[];
+}
+
+export type OrganSystem =
+  | 'Cardiovascular'
+  | 'Pulmonary'
+  | 'Endocrine'
+  | 'Neurologic'
+  | 'Musculoskeletal'
+  | 'Renal'
+  | 'Hepatic'
+  | 'Auditory'
+  | 'Ophthalmologic'
+  | 'Dermatologic'
+  | 'Reproductive'
+  | 'Immunologic'
+  | 'Gastrointestinal'
+  | 'Cognitive';
+
+export interface LateEffectRisk {
+  effect: string;
+  causingAgents: string[];
+  riskLevel: 'Low' | 'Moderate' | 'High';
+  typicalOnset: string;
+  reversibility: 'Reversible' | 'Partially Reversible' | 'Irreversible' | 'Often Irreversible';
+}
+
+export interface ScreeningItem {
+  test: string;
+  startTiming: string;
+  frequency: string;
+  abnormalThreshold: string;
+  action: string;
+}
+
+export interface ManagementGuideline {
+  condition: string;
+  interventions: string[];
+  referralIndications: string[];
+  preventiveMeasures: string[];
+}
+
+export interface SecondaryMalignancyScreen {
+  malignancyType: string;
+  riskFactors: string[];
+  latencyPeriod: string;
+  screeningRecommendation: string;
+  frequency: string;
+}
+
+export interface PsychosocialPlan {
+  riskFactors: string[];
+  assessmentTools: string[];
+  supportResources: SupportResource[];
+  interventions: PsychosocialIntervention[];
+}
+
+export interface SupportResource {
+  type: string;
+  description: string;
+  accessInstructions: string;
+}
+
+export interface PsychosocialIntervention {
+  indication: string;
+  intervention: string;
+  expectedBenefit: string;
+}
+
+export interface RehabilitationPlan {
+  physicalNeeds: RehabilitationNeed[];
+  vocationalConsiderations: string[];
+  adaptiveEquipment: string[];
+  exerciseRecommendations: ExerciseRecommendation[];
+}
+
+export interface RehabilitationNeed {
+  area: string;
+  assessment: string;
+  intervention: string;
+  goals: string[];
+}
+
+export interface ExerciseRecommendation {
+  type: 'Aerobic' | 'Resistance' | 'Flexibility' | 'Balance';
+  frequency: string;
+  intensity: string;
+  duration: string;
+  precautions: string[];
+  benefits: string[];
+}
+
+export interface HealthMaintenance {
+  category: string;
+  recommendations: string[];
+  frequency: string;
+}
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// SURVEILLANCE PROTOCOLS BY CANCER TYPE
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const SURVEILLANCE_PROTOCOLS: Record<string, SurveillanceProtocol> = {
+  'breast-early-stage': {
+    recurrenceRisk: 'Low',
+    duration: '10 years after diagnosis, then routine care',
+    visits: [
+      {
+        timing: 'Year 1-3: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review, breast/chest wall/axilla exam', frequency: 'Every 3-6 months', rationale: 'Early recurrence detection' },
+          { type: 'Imaging', specific: 'Mammogram', frequency: 'Annual', rationale: 'Ipsilateral (if BCT) and contralateral screening' },
+          { type: 'Laboratory', specific: 'Consider CBC, CMP if on endocrine therapy', frequency: 'Annual', rationale: 'Treatment monitoring' }
+        ],
+        purpose: 'Early recurrence detection, treatment adherence'
+      },
+      {
+        timing: 'Year 4-5: Every 6-12 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review, exam', frequency: 'Every 6-12 months', rationale: 'Recurrence surveillance' },
+          { type: 'Imaging', specific: 'Mammogram', frequency: 'Annual', rationale: 'Continued surveillance' }
+        ],
+        purpose: 'Ongoing surveillance'
+      },
+      {
+        timing: 'Year 6-10: Annual',
+        components: [
+          { type: 'History/Physical', specific: 'Annual exam', frequency: 'Annual', rationale: 'Late recurrence' },
+          { type: 'Imaging', specific: 'Mammogram', frequency: 'Annual', rationale: 'Continued surveillance' }
+        ],
+        purpose: 'Late recurrence detection'
+      },
+      {
+        timing: 'Beyond 10 years: Routine screening',
+        components: [
+          { type: 'Imaging', specific: 'Mammogram per guidelines', frequency: 'Annual', rationale: 'General breast cancer screening' }
+        ],
+        purpose: 'Transition to routine care'
+      }
+    ],
+    discontinuationCriteria: ['Patient preference', 'Limited life expectancy', 'Transition to palliative goals']
+  },
+
+  'colorectal-stage-ii-iii': {
+    recurrenceRisk: 'Intermediate',
+    duration: '5 years, then routine screening',
+    visits: [
+      {
+        timing: 'Year 1-2: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review, abdominal exam', frequency: 'Every 3-6 months', rationale: 'Early recurrence detection' },
+          { type: 'Biomarker', specific: 'CEA', frequency: 'Every 3-6 months', rationale: 'Rising CEA may indicate recurrence' },
+          { type: 'Imaging', specific: 'CT chest/abdomen/pelvis', frequency: 'Every 6-12 months', rationale: 'Metastatic surveillance' },
+          { type: 'Endoscopy', specific: 'Colonoscopy at 1 year post-surgery', frequency: 'Year 1', rationale: 'Anastomotic/metachronous lesions' }
+        ],
+        purpose: 'High-risk recurrence period'
+      },
+      {
+        timing: 'Year 3-5: Every 6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Exam', frequency: 'Every 6 months', rationale: 'Continued surveillance' },
+          { type: 'Biomarker', specific: 'CEA', frequency: 'Every 6 months', rationale: 'Recurrence marker' },
+          { type: 'Imaging', specific: 'CT annually', frequency: 'Annual', rationale: 'Metastatic surveillance' },
+          { type: 'Endoscopy', specific: 'Colonoscopy at 3 years, 5 years', frequency: 'Year 3, 5', rationale: 'Metachronous lesions' }
+        ],
+        purpose: 'Continued surveillance'
+      },
+      {
+        timing: 'Beyond 5 years',
+        components: [
+          { type: 'Endoscopy', specific: 'Colonoscopy every 3-5 years', frequency: 'Every 3-5 years', rationale: 'Metachronous cancer screening' }
+        ],
+        purpose: 'Transition to routine colonoscopy surveillance'
+      }
+    ],
+    discontinuationCriteria: ['5 years without recurrence for intensive surveillance', 'Poor candidate for salvage therapy']
+  },
+
+  'lung-nsclc-resected': {
+    recurrenceRisk: 'High',
+    duration: '5 years, potentially lifelong',
+    visits: [
+      {
+        timing: 'Year 1-2: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review, pulmonary exam', frequency: 'Every 3-6 months', rationale: 'Early recurrence detection' },
+          { type: 'Imaging', specific: 'Chest CT with contrast', frequency: 'Every 6 months', rationale: 'Thoracic recurrence/second primary' }
+        ],
+        purpose: 'High recurrence risk period'
+      },
+      {
+        timing: 'Year 3-5: Every 6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Exam', frequency: 'Every 6 months', rationale: 'Surveillance' },
+          { type: 'Imaging', specific: 'Chest CT', frequency: 'Every 6-12 months', rationale: 'Continued surveillance' }
+        ],
+        purpose: 'Ongoing recurrence risk'
+      },
+      {
+        timing: 'Beyond 5 years',
+        components: [
+          { type: 'Imaging', specific: 'Annual low-dose CT', frequency: 'Annual', rationale: 'Second primary lung cancer screening' }
+        ],
+        purpose: 'Second primary detection'
+      }
+    ],
+    discontinuationCriteria: ['Poor PS precluding further treatment', 'Patient preference']
+  },
+
+  'lymphoma-hodgkin': {
+    recurrenceRisk: 'Low',
+    duration: '5 years, then long-term late effects monitoring',
+    visits: [
+      {
+        timing: 'Year 1-2: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review (B symptoms), lymph node exam', frequency: 'Every 3-6 months', rationale: 'Early relapse detection' },
+          { type: 'Laboratory', specific: 'CBC, ESR, CMP', frequency: 'Every 3-6 months', rationale: 'Marrow function, inflammation' },
+          { type: 'Imaging', specific: 'CT or PET/CT', frequency: 'Every 6-12 months (consider less if low risk)', rationale: 'Recurrence detection' }
+        ],
+        purpose: 'Early relapse detection'
+      },
+      {
+        timing: 'Year 3-5: Every 6-12 months',
+        components: [
+          { type: 'History/Physical', specific: 'Exam', frequency: 'Every 6-12 months', rationale: 'Surveillance' },
+          { type: 'Laboratory', specific: 'CBC', frequency: 'Annual', rationale: 'Screen for secondary MDS/AML' }
+        ],
+        purpose: 'Reduced intensity surveillance'
+      },
+      {
+        timing: 'Beyond 5 years: Lifelong',
+        components: [
+          { type: 'History/Physical', specific: 'Annual with late effects focus', frequency: 'Annual', rationale: 'Late effects monitoring' }
+        ],
+        purpose: 'Late effects surveillance (cardiac, secondary malignancy)'
+      }
+    ],
+    discontinuationCriteria: ['Patient preference', 'Limited life expectancy from other causes']
+  },
+
+  'testicular-germ-cell': {
+    recurrenceRisk: 'Intermediate',
+    duration: '10 years (most relapses in first 2 years)',
+    visits: [
+      {
+        timing: 'Year 1: Every 2-3 months',
+        components: [
+          { type: 'History/Physical', specific: 'Symptom review, testicular exam', frequency: 'Every 2-3 months', rationale: 'Early relapse detection' },
+          { type: 'Biomarker', specific: 'AFP, HCG, LDH', frequency: 'Every 2-3 months', rationale: 'Tumor marker surveillance' },
+          { type: 'Imaging', specific: 'CT abdomen/pelvis', frequency: 'Every 3-6 months (protocol dependent)', rationale: 'Retroperitoneal surveillance' }
+        ],
+        purpose: 'Highest risk period'
+      },
+      {
+        timing: 'Year 2-5: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Exam', frequency: 'Every 3-6 months', rationale: 'Surveillance' },
+          { type: 'Biomarker', specific: 'Tumor markers', frequency: 'Every 3-6 months', rationale: 'Recurrence detection' },
+          { type: 'Imaging', specific: 'CT annually', frequency: 'Annual', rationale: 'Surveillance imaging' }
+        ],
+        purpose: 'Continued surveillance'
+      },
+      {
+        timing: 'Year 6-10: Annual',
+        components: [
+          { type: 'History/Physical', specific: 'Exam', frequency: 'Annual', rationale: 'Late relapse rare but possible' },
+          { type: 'Biomarker', specific: 'Tumor markers', frequency: 'Annual', rationale: 'Late relapse detection' }
+        ],
+        purpose: 'Late relapse surveillance'
+      }
+    ],
+    discontinuationCriteria: ['10 years without relapse', 'Patient preference']
+  },
+
+  'melanoma-resected': {
+    recurrenceRisk: 'Intermediate',
+    duration: 'Lifelong (risk of late recurrence and new primaries)',
+    visits: [
+      {
+        timing: 'Year 1-2: Every 3-6 months',
+        components: [
+          { type: 'History/Physical', specific: 'Complete skin exam, lymph node exam', frequency: 'Every 3-6 months', rationale: 'Local/regional recurrence, new primaries' },
+          { type: 'Imaging', specific: 'Consider CT or PET/CT for stage IIB+ every 3-12 months', frequency: 'Per stage', rationale: 'Distant recurrence' }
+        ],
+        purpose: 'Early recurrence detection'
+      },
+      {
+        timing: 'Year 3-5: Every 6-12 months',
+        components: [
+          { type: 'History/Physical', specific: 'Skin and node exam', frequency: 'Every 6-12 months', rationale: 'Surveillance' },
+          { type: 'Imaging', specific: 'CT annually for high-risk', frequency: 'Annual', rationale: 'Distant surveillance' }
+        ],
+        purpose: 'Ongoing surveillance'
+      },
+      {
+        timing: 'Beyond 5 years: Lifelong',
+        components: [
+          { type: 'History/Physical', specific: 'Annual dermatologic exam', frequency: 'Annual', rationale: 'Second primaries, late recurrence' }
+        ],
+        purpose: 'Lifelong skin surveillance'
+      }
+    ],
+    discontinuationCriteria: ['Patient preference - skin exams should continue indefinitely']
+  }
+};
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// LATE EFFECTS SCREENING PROTOCOLS
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const LATE_EFFECTS_PROTOCOLS: LateEffectsScreening[] = [
+  {
+    system: 'Cardiovascular',
+    risks: [
+      {
+        effect: 'Cardiomyopathy',
+        causingAgents: ['Anthracyclines (doxorubicin, daunorubicin)', 'Trastuzumab', 'Chest radiation'],
+        riskLevel: 'High',
+        typicalOnset: 'Months to years after treatment',
+        reversibility: 'Partially Reversible'
+      },
+      {
+        effect: 'Coronary Artery Disease',
+        causingAgents: ['Chest/mediastinal radiation', 'Cisplatin', 'Hormonal therapy'],
+        riskLevel: 'Moderate',
+        typicalOnset: '5-20 years post-treatment',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Valvular Heart Disease',
+        causingAgents: ['Chest radiation'],
+        riskLevel: 'Moderate',
+        typicalOnset: '10-20 years post-radiation',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Arrhythmias',
+        causingAgents: ['Anthracyclines', 'Targeted therapies (ibrutinib)', 'Radiation'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Variable',
+        reversibility: 'Partially Reversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'Echocardiogram',
+        startTiming: 'Baseline, then 6-12 months after anthracycline completion',
+        frequency: 'Every 1-5 years based on risk and baseline function',
+        abnormalThreshold: 'LVEF <50% or decline >10% from baseline',
+        action: 'Cardio-oncology referral, consider ACE-I/ARB/BB'
+      },
+      {
+        test: 'Lipid Panel',
+        startTiming: 'Annually after treatment',
+        frequency: 'Annual',
+        abnormalThreshold: 'Per standard guidelines',
+        action: 'Lifestyle modification, statin if indicated'
+      },
+      {
+        test: 'Blood Pressure',
+        startTiming: 'Every visit',
+        frequency: 'Every visit',
+        abnormalThreshold: '≥130/80',
+        action: 'Lifestyle modification, antihypertensive therapy'
+      },
+      {
+        test: 'ECG',
+        startTiming: 'If arrhythmia symptoms',
+        frequency: 'As needed',
+        abnormalThreshold: 'Arrhythmia, prolonged QTc',
+        action: 'Cardiology referral'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Asymptomatic LV dysfunction',
+        interventions: ['ACE-I or ARB', 'Beta-blocker', 'Exercise as tolerated'],
+        referralIndications: ['LVEF <40%', 'Symptoms of heart failure', 'Significant decline'],
+        preventiveMeasures: ['Cardiovascular risk factor modification', 'Exercise', 'Dexrazoxane during anthracycline (selected cases)']
+      },
+      {
+        condition: 'Heart failure',
+        interventions: ['Guideline-directed medical therapy', 'Heart failure specialist referral'],
+        referralIndications: ['All symptomatic HF'],
+        preventiveMeasures: ['Early detection and intervention']
+      }
+    ]
+  },
+  {
+    system: 'Pulmonary',
+    risks: [
+      {
+        effect: 'Pulmonary Fibrosis',
+        causingAgents: ['Bleomycin', 'Busulfan', 'Carmustine', 'Radiation to chest'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Months to years',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Pneumonitis',
+        causingAgents: ['Immune checkpoint inhibitors', 'mTOR inhibitors', 'Radiation'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Weeks to months',
+        reversibility: 'Partially Reversible'
+      },
+      {
+        effect: 'Restrictive Lung Disease',
+        causingAgents: ['Chest radiation', 'Thoracic surgery'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Years',
+        reversibility: 'Irreversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'Pulmonary Function Tests (PFTs)',
+        startTiming: 'Baseline and post-treatment for high-risk agents',
+        frequency: 'Every 1-2 years for high-risk, as needed for others',
+        abnormalThreshold: 'DLCO <60% predicted or decline >15%',
+        action: 'Pulmonology referral, oxygen evaluation'
+      },
+      {
+        test: 'Symptom Assessment',
+        startTiming: 'Every visit',
+        frequency: 'Every visit',
+        abnormalThreshold: 'New dyspnea, cough, decreased exercise tolerance',
+        action: 'PFTs, imaging, pulmonology referral'
+      },
+      {
+        test: 'Chest X-ray or CT',
+        startTiming: 'If symptomatic',
+        frequency: 'As needed',
+        abnormalThreshold: 'New infiltrates, fibrosis, nodules',
+        action: 'Pulmonology referral'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Pulmonary fibrosis',
+        interventions: ['Supportive care', 'Oxygen if hypoxic', 'Pulmonary rehabilitation'],
+        referralIndications: ['Symptomatic fibrosis', 'Hypoxia'],
+        preventiveMeasures: ['Avoid additional lung toxins', 'Smoking cessation', 'Influenza and pneumococcal vaccination']
+      }
+    ]
+  },
+  {
+    system: 'Endocrine',
+    risks: [
+      {
+        effect: 'Hypothyroidism',
+        causingAgents: ['Neck radiation', 'TKIs (sunitinib, sorafenib)', 'Immune checkpoint inhibitors', 'Radioiodine'],
+        riskLevel: 'High',
+        typicalOnset: 'Months to years',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Hyperthyroidism (transient)',
+        causingAgents: ['Immune checkpoint inhibitors'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Weeks to months',
+        reversibility: 'Reversible'
+      },
+      {
+        effect: 'Adrenal Insufficiency',
+        causingAgents: ['Immune checkpoint inhibitors', 'Prolonged steroids', 'Brain radiation'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'Variable',
+        reversibility: 'Often Irreversible'
+      },
+      {
+        effect: 'Hypogonadism',
+        causingAgents: ['Alkylating agents', 'GnRH agonists', 'Pelvic/gonadal radiation', 'Orchiectomy/oophorectomy'],
+        riskLevel: 'High',
+        typicalOnset: 'During or after treatment',
+        reversibility: 'Often Irreversible'
+      },
+      {
+        effect: 'Growth Hormone Deficiency',
+        causingAgents: ['Cranial radiation (>18 Gy)'],
+        riskLevel: 'High',
+        typicalOnset: 'Months to years',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Diabetes/Glucose Intolerance',
+        causingAgents: ['Steroids', 'L-asparaginase', 'mTOR inhibitors', 'Pancreatectomy'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'During treatment or after',
+        reversibility: 'Partially Reversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'TSH',
+        startTiming: 'Annually after neck radiation or thyroid-toxic therapy',
+        frequency: 'Annual',
+        abnormalThreshold: 'TSH elevated or suppressed',
+        action: 'Free T4, endocrine referral if needed'
+      },
+      {
+        test: 'Morning Cortisol',
+        startTiming: 'If fatigue, hypotension, or high-risk for adrenal insufficiency',
+        frequency: 'As indicated',
+        abnormalThreshold: '<3 mcg/dL indicates insufficiency, 3-15 needs stim test',
+        action: 'ACTH stimulation test, endocrine referral'
+      },
+      {
+        test: 'Sex Hormones (Testosterone, Estradiol, FSH, LH)',
+        startTiming: '6-12 months post-treatment if at risk',
+        frequency: 'Annual if abnormal or symptomatic',
+        abnormalThreshold: 'Low testosterone or estradiol with elevated FSH/LH',
+        action: 'Endocrine referral, consider hormone replacement'
+      },
+      {
+        test: 'HbA1c or Fasting Glucose',
+        startTiming: 'Annually',
+        frequency: 'Annual',
+        abnormalThreshold: 'HbA1c ≥5.7% or FG ≥100',
+        action: 'Diabetes prevention/management'
+      },
+      {
+        test: 'Bone Density (DEXA)',
+        startTiming: 'Baseline if on hormonal therapy or at risk',
+        frequency: 'Every 1-2 years',
+        abnormalThreshold: 'T-score ≤-2.5 (osteoporosis) or ≤-1.0 (osteopenia)',
+        action: 'Calcium/Vitamin D, consider bisphosphonate'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Hypothyroidism',
+        interventions: ['Levothyroxine replacement'],
+        referralIndications: ['Complex dosing', 'Pregnancy'],
+        preventiveMeasures: ['Regular monitoring']
+      },
+      {
+        condition: 'Adrenal insufficiency',
+        interventions: ['Hydrocortisone replacement', 'Stress dosing education'],
+        referralIndications: ['All cases'],
+        preventiveMeasures: ['Medical alert bracelet']
+      },
+      {
+        condition: 'Premature ovarian insufficiency',
+        interventions: ['Hormone replacement therapy (if appropriate)', 'Calcium/Vitamin D'],
+        referralIndications: ['Fertility counseling', 'HRT management'],
+        preventiveMeasures: ['Fertility preservation before treatment']
+      }
+    ]
+  },
+  {
+    system: 'Cognitive',
+    risks: [
+      {
+        effect: 'Chemotherapy-related cognitive impairment ("chemo brain")',
+        causingAgents: ['Many chemotherapy agents', 'Hormonal therapy'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'During or after treatment',
+        reversibility: 'Partially Reversible'
+      },
+      {
+        effect: 'Radiation-induced cognitive decline',
+        causingAgents: ['Whole brain radiation', 'Cranial radiation'],
+        riskLevel: 'High',
+        typicalOnset: 'Months to years',
+        reversibility: 'Irreversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'Cognitive symptom assessment',
+        startTiming: 'Every visit',
+        frequency: 'Every visit',
+        abnormalThreshold: 'Subjective complaints affecting function',
+        action: 'Formal neuropsychological testing'
+      },
+      {
+        test: 'Neuropsychological testing',
+        startTiming: 'If symptomatic or high-risk',
+        frequency: 'As indicated',
+        abnormalThreshold: 'Objective deficits',
+        action: 'Cognitive rehabilitation, neurology referral'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Cognitive impairment',
+        interventions: ['Cognitive rehabilitation', 'Memory strategies', 'Occupational therapy', 'Consider methylphenidate or modafinil'],
+        referralIndications: ['Significant functional impairment'],
+        preventiveMeasures: ['Memantine during WBRT (limited evidence)', 'Hippocampal-sparing radiation techniques']
+      }
+    ]
+  },
+  {
+    system: 'Reproductive',
+    risks: [
+      {
+        effect: 'Infertility',
+        causingAgents: ['Alkylating agents', 'Pelvic/gonadal radiation', 'Gonadectomy'],
+        riskLevel: 'High',
+        typicalOnset: 'During treatment',
+        reversibility: 'Often Irreversible'
+      },
+      {
+        effect: 'Premature menopause',
+        causingAgents: ['Alkylating chemotherapy', 'Pelvic radiation', 'Oophorectomy'],
+        riskLevel: 'High',
+        typicalOnset: 'During or after treatment',
+        reversibility: 'Irreversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'FSH, LH, AMH (females), Testosterone (males)',
+        startTiming: '6-12 months post-treatment',
+        frequency: 'As needed',
+        abnormalThreshold: 'Elevated FSH, low AMH (females); low testosterone (males)',
+        action: 'Reproductive endocrinology referral if family planning desired'
+      },
+      {
+        test: 'Semen analysis (males)',
+        startTiming: '1-2 years post-treatment if fertility desired',
+        frequency: 'As needed',
+        abnormalThreshold: 'Azoospermia or oligospermia',
+        action: 'Urology/reproductive medicine referral'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Infertility',
+        interventions: ['Assisted reproductive technologies', 'Use of cryopreserved gametes/embryos', 'Donor options', 'Adoption counseling'],
+        referralIndications: ['Desire for biological children'],
+        preventiveMeasures: ['Fertility preservation before treatment (sperm banking, oocyte/embryo cryopreservation)']
+      }
+    ]
+  },
+  {
+    system: 'Auditory',
+    risks: [
+      {
+        effect: 'Ototoxicity/Hearing Loss',
+        causingAgents: ['Cisplatin', 'Carboplatin (high doses)', 'Cranial radiation'],
+        riskLevel: 'High',
+        typicalOnset: 'During or after treatment',
+        reversibility: 'Irreversible'
+      },
+      {
+        effect: 'Tinnitus',
+        causingAgents: ['Platinum agents'],
+        riskLevel: 'Moderate',
+        typicalOnset: 'During treatment',
+        reversibility: 'Often Irreversible'
+      }
+    ],
+    screeningProtocol: [
+      {
+        test: 'Audiometry',
+        startTiming: 'Baseline and post-treatment for platinum recipients',
+        frequency: 'As needed based on symptoms',
+        abnormalThreshold: 'High-frequency hearing loss',
+        action: 'Audiology referral, hearing aids if indicated'
+      }
+    ],
+    managementGuidance: [
+      {
+        condition: 'Hearing loss',
+        interventions: ['Hearing aids', 'Cochlear implants (severe cases)', 'Communication strategies'],
+        referralIndications: ['Symptomatic hearing loss'],
+        preventiveMeasures: ['Sodium thiosulfate (pediatric, localized tumors)', 'Avoid noise exposure']
+      }
+    ]
+  }
+];
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// SECONDARY MALIGNANCY SCREENING
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const SECONDARY_MALIGNANCY_SCREENING: SecondaryMalignancyScreen[] = [
+  {
+    malignancyType: 'Breast Cancer',
+    riskFactors: ['Chest/mediastinal radiation (especially <30 years old)', 'BRCA mutation carriers'],
+    latencyPeriod: '8-10 years post-radiation',
+    screeningRecommendation: 'Annual mammogram + breast MRI starting 8 years post-RT or age 25 (whichever later)',
+    frequency: 'Annual'
+  },
+  {
+    malignancyType: 'Thyroid Cancer',
+    riskFactors: ['Neck/chest radiation (especially pediatric)'],
+    latencyPeriod: '5-20 years',
+    screeningRecommendation: 'Annual thyroid exam, consider thyroid ultrasound',
+    frequency: 'Annual exam, US as indicated'
+  },
+  {
+    malignancyType: 'Therapy-related MDS/AML',
+    riskFactors: ['Alkylating agents', 'Topoisomerase II inhibitors', 'Prior chemoradiation'],
+    latencyPeriod: '2-10 years (alkylators 5-10y, topo II 2-3y)',
+    screeningRecommendation: 'Annual CBC with differential',
+    frequency: 'Annual for 10 years'
+  },
+  {
+    malignancyType: 'Lung Cancer',
+    riskFactors: ['Smoking history', 'Chest radiation', 'Alkylating agents'],
+    latencyPeriod: '5-20 years',
+    screeningRecommendation: 'Low-dose CT if smoking history meets criteria (separate from cancer surveillance)',
+    frequency: 'Annual LDCT per USPSTF criteria'
+  },
+  {
+    malignancyType: 'Colorectal Cancer',
+    riskFactors: ['Abdominal/pelvic radiation', 'Lynch syndrome'],
+    latencyPeriod: '10-15 years',
+    screeningRecommendation: 'Colonoscopy per guidelines, may start earlier if radiation exposure',
+    frequency: 'Every 5-10 years or per findings'
+  },
+  {
+    malignancyType: 'Skin Cancer (non-melanoma and melanoma)',
+    riskFactors: ['Radiation (any site)', 'Immunosuppression', 'PUVA therapy'],
+    latencyPeriod: 'Variable',
+    screeningRecommendation: 'Annual dermatologic exam',
+    frequency: 'Annual'
+  },
+  {
+    malignancyType: 'Sarcoma',
+    riskFactors: ['Prior radiation therapy'],
+    latencyPeriod: '10-20 years',
+    screeningRecommendation: 'Clinical exam of radiation field, imaging if symptomatic',
+    frequency: 'Every visit'
+  },
+  {
+    malignancyType: 'Bladder Cancer',
+    riskFactors: ['Cyclophosphamide', 'Ifosfamide'],
+    latencyPeriod: '5-15 years',
+    screeningRecommendation: 'Urinalysis for hematuria, cystoscopy if hematuria',
+    frequency: 'Annual urinalysis'
+  }
+];
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// PSYCHOSOCIAL SUPPORT FRAMEWORK
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const PSYCHOSOCIAL_SUPPORT_FRAMEWORK: PsychosocialPlan = {
+  riskFactors: [
+    'Young age at diagnosis',
+    'Intensive treatment',
+    'Visible disfigurement',
+    'Pre-existing mental health conditions',
+    'Limited social support',
+    'Financial hardship',
+    'Loss of employment',
+    'Relationship difficulties',
+    'Fertility impact'
+  ],
+  assessmentTools: [
+    'Distress Thermometer',
+    'PHQ-9 (depression)',
+    'GAD-7 (anxiety)',
+    'FACT-G (quality of life)',
+    'FACIT-Fatigue',
+    'Fear of Cancer Recurrence Inventory',
+    'Cancer Worry Scale'
+  ],
+  supportResources: [
+    {
+      type: 'Individual Counseling',
+      description: 'One-on-one therapy with licensed mental health professional experienced in oncology',
+      accessInstructions: 'Referral through oncology social work or direct contact with cancer center psychology'
+    },
+    {
+      type: 'Support Groups',
+      description: 'Peer support groups for cancer survivors (in-person or virtual)',
+      accessInstructions: 'Cancer center resources, American Cancer Society, CancerCare'
+    },
+    {
+      type: 'Financial Counseling',
+      description: 'Assistance with insurance, disability, employment issues',
+      accessInstructions: 'Oncology social work, Patient Advocate Foundation'
+    },
+    {
+      type: 'Nutrition Counseling',
+      description: 'Registered dietitian specializing in oncology',
+      accessInstructions: 'Referral through oncology team'
+    },
+    {
+      type: 'Sexual Health Counseling',
+      description: 'Address treatment-related sexual dysfunction',
+      accessInstructions: 'Gynecologic oncology, urology, certified sexual health counselor'
+    },
+    {
+      type: 'Palliative Care/Supportive Care',
+      description: 'Symptom management and quality of life focus',
+      accessInstructions: 'Referral through oncology team'
+    },
+    {
+      type: 'Cancer Rehabilitation',
+      description: 'Physical, occupational, speech therapy for cancer-related impairments',
+      accessInstructions: 'Physiatry referral, cancer rehabilitation programs'
+    }
+  ],
+  interventions: [
+    {
+      indication: 'Depression (PHQ-9 ≥10)',
+      intervention: 'Psychotherapy (CBT, supportive), consider antidepressant medication',
+      expectedBenefit: 'Improved mood, functioning, quality of life'
+    },
+    {
+      indication: 'Anxiety (GAD-7 ≥10)',
+      intervention: 'CBT, relaxation training, consider anxiolytic medication',
+      expectedBenefit: 'Reduced anxiety, improved coping'
+    },
+    {
+      indication: 'Fear of recurrence',
+      intervention: 'Fear of Cancer Recurrence CBT, mindfulness-based interventions',
+      expectedBenefit: 'Reduced fear, improved quality of life'
+    },
+    {
+      indication: 'Fatigue',
+      intervention: 'Exercise program, sleep hygiene, energy conservation, consider methylphenidate',
+      expectedBenefit: 'Improved energy, function'
+    },
+    {
+      indication: 'Sleep disturbance',
+      intervention: 'CBT-I (cognitive behavioral therapy for insomnia), sleep hygiene',
+      expectedBenefit: 'Improved sleep quality'
+    },
+    {
+      indication: 'Body image concerns',
+      intervention: 'Individual therapy, support groups, prosthetics/reconstruction counseling',
+      expectedBenefit: 'Improved self-image, adjustment'
+    }
+  ]
+};
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// EXERCISE AND REHABILITATION
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const EXERCISE_RECOMMENDATIONS: ExerciseRecommendation[] = [
+  {
+    type: 'Aerobic',
+    frequency: '3-5 days per week',
+    intensity: 'Moderate intensity (64-76% max HR, somewhat hard)',
+    duration: '150 minutes/week moderate or 75 minutes/week vigorous',
+    precautions: [
+      'Start slowly if deconditioned',
+      'Avoid high-impact if bone metastases or lymphedema',
+      'Monitor for cardiac symptoms if prior cardiotoxic therapy',
+      'May need medical clearance for vigorous exercise'
+    ],
+    benefits: [
+      'Reduced fatigue',
+      'Improved cardiovascular fitness',
+      'Better quality of life',
+      'Reduced risk of recurrence (breast, colon)',
+      'Improved mood and sleep'
+    ]
+  },
+  {
+    type: 'Resistance',
+    frequency: '2-3 days per week',
+    intensity: '60-80% 1-rep max, 8-12 repetitions, 2-3 sets',
+    duration: '20-30 minutes per session',
+    precautions: [
+      'Avoid heavy lifting if lymphedema risk (may do gradual progressive)',
+      'Avoid if severe thrombocytopenia (<50K)',
+      'Modify if bone metastases',
+      'Proper form to prevent injury'
+    ],
+    benefits: [
+      'Maintain/improve muscle mass',
+      'Improved functional capacity',
+      'Reduced fatigue',
+      'Improved bone density'
+    ]
+  },
+  {
+    type: 'Flexibility',
+    frequency: 'Daily or most days',
+    intensity: 'Stretch to point of mild discomfort, not pain',
+    duration: '10-15 minutes',
+    precautions: [
+      'Gentle stretching post-surgery',
+      'Avoid overstretching if radiation fibrosis'
+    ],
+    benefits: [
+      'Improved range of motion',
+      'Reduced stiffness',
+      'Improved posture'
+    ]
+  },
+  {
+    type: 'Balance',
+    frequency: '2-3 days per week',
+    intensity: 'Challenging but safe',
+    duration: '10-15 minutes',
+    precautions: [
+      'Use support if peripheral neuropathy',
+      'Fall prevention strategies'
+    ],
+    benefits: [
+      'Reduced fall risk (especially if neuropathy)',
+      'Improved function'
+    ]
+  }
+];
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// HEALTH MAINTENANCE RECOMMENDATIONS
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export const HEALTH_MAINTENANCE_RECOMMENDATIONS: HealthMaintenance[] = [
+  {
+    category: 'Vaccinations',
+    recommendations: [
+      'Annual influenza vaccine',
+      'Pneumococcal vaccine (PCV20 or PCV15 + PPSV23)',
+      'COVID-19 vaccine series and boosters',
+      'Shingrix (recombinant zoster vaccine) - 2 doses',
+      'Tdap and Td boosters',
+      'Hepatitis B if not immune',
+      'HPV vaccine if eligible (≤26, or 27-45 with shared decision making)'
+    ],
+    frequency: 'Per CDC guidelines; annual flu, others per schedule'
+  },
+  {
+    category: 'Lifestyle Modifications',
+    recommendations: [
+      'Smoking cessation (if applicable)',
+      'Limit alcohol (≤1 drink/day women, ≤2 drinks/day men)',
+      'Maintain healthy weight (BMI 18.5-24.9)',
+      'Heart-healthy diet (Mediterranean, DASH)',
+      'Regular physical activity (per exercise recommendations)',
+      'Sun protection (sunscreen, protective clothing)',
+      'Stress management techniques'
+    ],
+    frequency: 'Ongoing'
+  },
+  {
+    category: 'Age-appropriate Cancer Screening',
+    recommendations: [
+      'Breast: Mammography per guidelines (may be modified based on prior treatment)',
+      'Colorectal: Colonoscopy or alternative per guidelines',
+      'Cervical: Pap/HPV testing per guidelines if cervix present',
+      'Prostate: Shared decision making per guidelines',
+      'Lung: Low-dose CT if meets USPSTF criteria',
+      'Skin: Annual dermatologic exam (especially if prior treatment)'
+    ],
+    frequency: 'Per age-appropriate guidelines'
+  },
+  {
+    category: 'Bone Health',
+    recommendations: [
+      'Calcium 1000-1200 mg/day (diet + supplements if needed)',
+      'Vitamin D 600-800 IU/day (may need higher if deficient)',
+      'Weight-bearing exercise',
+      'DEXA scan if on aromatase inhibitors, GnRH agonists, or steroids',
+      'Bisphosphonate or denosumab if osteoporosis'
+    ],
+    frequency: 'Daily supplements; DEXA every 1-2 years if at risk'
+  },
+  {
+    category: 'Cardiovascular Health',
+    recommendations: [
+      'Blood pressure monitoring and control',
+      'Lipid management per guidelines',
+      'Diabetes prevention/management',
+      'Aspirin if indicated for cardiovascular prevention',
+      'Cardiac-protective diet'
+    ],
+    frequency: 'Regular monitoring per guidelines'
+  },
+  {
+    category: 'Dental Health',
+    recommendations: [
+      'Regular dental care',
+      'Dental evaluation before bisphosphonates/denosumab',
+      'Avoid invasive dental procedures on bisphosphonates/denosumab (or discuss with oncology)',
+      'Manage xerostomia if radiation to H&N'
+    ],
+    frequency: 'Every 6-12 months'
+  }
+];
+
+// ═══════════════════════════════════════════════════════════════════════════════
+// SURVIVORSHIP CARE ENGINE
+// ═══════════════════════════════════════════════════════════════════════════════
+
+export class SurvivorshipCareEngine {
+  getSurveillanceProtocol(cancerType: string): SurveillanceProtocol | undefined {
+    return SURVEILLANCE_PROTOCOLS[cancerType];
+  }
+
+  getLateEffectsScreening(treatments: string[]): LateEffectsScreening[] {
+    const relevantScreenings: LateEffectsScreening[] = [];
+
+    for (const screening of LATE_EFFECTS_PROTOCOLS) {
+      const hasRelevantExposure = screening.risks.some(risk =>
+        risk.causingAgents.some(agent =>
+          treatments.some(t => t.toLowerCase().includes(agent.toLowerCase()) ||
+            agent.toLowerCase().includes(t.toLowerCase()))
+        )
+      );
+      if (hasRelevantExposure) {
+        relevantScreenings.push(screening);
+      }
+    }
+
+    return relevantScreenings;
+  }
+
+  getSecondaryMalignancyScreening(treatmentHistory: { chemotherapy: string[]; radiation: string[] }): SecondaryMalignancyScreen[] {
+    const relevantScreens: SecondaryMalignancyScreen[] = [];
+
+    for (const screen of SECONDARY_MALIGNANCY_SCREENING) {
+      const hasRisk = screen.riskFactors.some(factor => {
+        const factorLower = factor.toLowerCase();
+        const hasChemoRisk = treatmentHistory.chemotherapy.some(c =>
+          factorLower.includes(c.toLowerCase()) || c.toLowerCase().includes(factorLower)
+        );
+        const hasRadRisk = treatmentHistory.radiation.some(r =>
+          factorLower.includes(r.toLowerCase()) || r.toLowerCase().includes(factorLower)
+        );
+        return hasChemoRisk || hasRadRisk;
+      });
+      if (hasRisk) {
+        relevantScreens.push(screen);
+      }
+    }
+
+    return relevantScreens;
+  }
+
+  generateSurvivorshipCarePlan(
+    cancerType: string,
+    stage: string,
+    treatmentSummary: TreatmentSummary
+  ): SurvivorshipCareplan {
+    const surveillanceKey = `${cancerType.toLowerCase().replace(/\s+/g, '-')}-${stage.toLowerCase().replace(/\s+/g, '-')}`;
+    const surveillanceProtocol = SURVEILLANCE_PROTOCOLS[surveillanceKey] || {
+      recurrenceRisk: 'Intermediate' as const,
+      duration: 'Per oncologist recommendation',
+      visits: [],
+      discontinuationCriteria: []
+    };
+
+    // Collect all treatment agents for late effects screening
+    const allAgents: string[] = [];
+    for (const sys of treatmentSummary.systemicTherapy) {
+      allAgents.push(...sys.specificAgents, sys.agentClass);
+    }
+    for (const rad of treatmentSummary.radiation) {
+      allAgents.push(rad.site, rad.modality);
+    }
+
+    const lateEffectsScreening = this.getLateEffectsScreening(allAgents);
+
+    const chemoAgents = treatmentSummary.systemicTherapy.flatMap(s => s.specificAgents);
+    const radSites = treatmentSummary.radiation.map(r => r.site);
+    const secondaryMalignancyScreening = this.getSecondaryMalignancyScreening({
+      chemotherapy: chemoAgents,
+      radiation: radSites
+    });
+
+    const rehabilitationNeeds: RehabilitationPlan = {
+      physicalNeeds: [],
+      vocationalConsiderations: [
+        'Discuss return to work timeline',
+        'May need workplace accommodations',
+        'Consider vocational rehabilitation if career change needed'
+      ],
+      adaptiveEquipment: [],
+      exerciseRecommendations: EXERCISE_RECOMMENDATIONS
+    };
+
+    // Add specific rehab needs based on treatment
+    if (treatmentSummary.surgery.some(s => s.procedure.toLowerCase().includes('mastectomy'))) {
+      rehabilitationNeeds.physicalNeeds.push({
+        area: 'Upper extremity',
+        assessment: 'Range of motion, strength, lymphedema risk',
+        intervention: 'Physical therapy, lymphedema precautions',
+        goals: ['Full shoulder ROM', 'Lymphedema prevention', 'Return to function']
+      });
+    }
+
+    return {
+      cancerType,
+      stage,
+      treatmentReceived: treatmentSummary,
+      surveillanceProtocol,
+      lateEffectsScreening,
+      secondaryMalignancyScreening,
+      psychosocialSupport: PSYCHOSOCIAL_SUPPORT_FRAMEWORK,
+      rehabilitationNeeds,
+      healthMaintenanceRecommendations: HEALTH_MAINTENANCE_RECOMMENDATIONS
+    };
+  }
+
+  getExerciseRecommendations(): ExerciseRecommendation[] {
+    return EXERCISE_RECOMMENDATIONS;
+  }
+
+  getHealthMaintenanceRecommendations(): HealthMaintenance[] {
+    return HEALTH_MAINTENANCE_RECOMMENDATIONS;
+  }
+
+  getPsychosocialResources(): PsychosocialPlan {
+    return PSYCHOSOCIAL_SUPPORT_FRAMEWORK;
+  }
+}
+
+// Export singleton instance
+export const survivorshipCareEngine = new SurvivorshipCareEngine();