Children with Cancer

1. Children with Cancer NUR 264 Pediatrics Julianna Maynor, RN, MSN

2. Developmental Differences • Childhood malignances arise from embryonic tissue • Environmental factors do not play as large a part in childhood cancers as they do in adult cancers • Diagnosis of cancer in children is usually made when symptoms warrant a diagnostic work-up • Few preventative strategies are known for childhood cancer • Metatstatic disease is often present at diagnosis of childhood cancers • Childhood cancers are more responsive to treatment • Childhood cancers have a greater than 70% cure rate

3. Cardinal Symptoms of Cancer • Unusual mass or swelling • Unexplained paleness and loss of energy • Sudden tendency to bruise • Persistent, localized pain or limping • Prolonged, unexplained fever or illness • Frequent headaches, often with vomiting • Sudden eye or vision changes • Excessive, rapid weight loss

4. Diagnostic Assessment • History and physical exam • Lab tests: CBC (decreased H&H, increased immature cells), chemistry (abnormal renal &liver function, electrolyte balance), UA, lumbar puncture • Imaging studies: x-rays, IVP, CT scans, US, nuclear scan, MRI • Biopsy • Classification –biological characteristics of tumor • Staging – extent of disease at time of diagnosis (higher the stage, poorer the prognosis)

5. Diagnostic Assessment • Bone marrow studies: when concern for metastasis or when primary site is blood forming organ to determine extent of involvement by malignant cells • Aspiration – obtain marrow through needle • Biopsy – obtain piece of bone through special needle

6. Cancer Treatment • Goal of treatment is to remove all malignant cells from the body. Therapy may include: • Surgery • Chemotherapy • Radiation therapy • Bone marrow transplant • Biological response modifiers

7. Cancer Treatment: Surgery • Obtain biopsy • Aids in tumor staging by noting the presence and extent of metastasis • Remove tumor • Restore body function

8. Cancer Treatment: Chemotherapy • Primary form of treatment or adjunct to surgery and/or radiation • Used for systemic cancers that cannot be managed by surgery or radiation • Combination of drugs – for optimum cancer cell cycle destruction with minimum toxic effects

9. Cancer Treatment: Chemotherapy • Use access ports to minimize multiple venipunctures • Use continuous infusions over extended period via syringe pumps for decreased toxicity, such as when intermittent dosages are given • Healthy cells are susceptible to damage • Causes bone marrow suppression – fatigue, anemia, bleeding tendencies, increased risk of infection

10. Chemotherapy: Three phases • Induction: Initial therapy • Goals: To eliminate as many cancer cells as possible • To obtain a complete remission • Consolidation: Given after remission is complete • Goal: To ensure complete eradication of disease • Maintenance: Given for several months to years after consolidation, depending on disease • Goals: To maintain a complete remission • To minimize late effects • To prevent drug resistance from developing

11. Cancer Treatment: ChemotherapyPotential Complications • Vesicants: severe cellular damage if infiltrate • Side effects affecting almost every body system • Anaphylaxis: cyanosis, hypotension, wheezing, severe uticaria. Can be fatal – discontinue drug, flush IV with saline and monitor VS • Hypersensitivity: rash, itching, flushing, hypotension, angioedema. When administering – wear gown, gloves, mask, goggles to prevent any physical contact. Discard ampules and syringes in special containers

12. Chemotherapy Side Effects • Hematopoietic effects • Myelosuppression (transient decrease in blood cell production) • Anemia: may require blood transfusions • Thrombocytopenia • Immunosuppression • Neutropenia (abnormal decrease in number of WBC) • Gastrointestinal effects • Stomatitis (inflammation of the oral mucosa. May be mild to severe and may affect the entire GI tract) • Nausea • Vomiting • Anorexia

13. Chemotherapy Side Effects • Hepatic effects • Liver toxicity • Renal effects • Renal toxicity • Hemorrhagic cystitis • Integumentary effects • Hair loss • Reproductive effects • Sterility • Delayed puberty

14. Cancer Treatment: Radiation Therapy • Used to deliver a therapeutic dose of ionizing radiation to a a tumor with minimal effects to the healthy surrounding tissue • Causes breaks in DNA molecules to destroy the cancer cells • Many side effects • Radiation pneumonitis • Somnolence syndrome

15. Cancer Treatment: Bone Marrow Transplant • Allows lethal doses of chemotherapy and radiation to be given • After chemotherapeutic agents are given, bone marrow or stem cells are transfused to patient to allow nonmalignant blood cells to function • Types of bone marrow transplant • Autologous: patient receives own marrow • Allogenic: patient receives donor marrow, must match as close as possible • Syngeneic: patient receives marrow from identical twin • Umbilical cord blood stem cells: may use unmatched donor

16. Cancer Treatment: Biologic Response Modifiers • Stimulate immune system to respond aggressively to tumor or to attack tumor cells with antibodies • Monoclonal antibodies: early cancer detection, to reduce graft vs. host disease, destroy malignant cells from autologous bone marrow for retransplant • Immune stimulants: interferon, interleukin

17. Complications of Cancer Treatment • Acute tumor lysis syndrome: Occurs when a large number of tumor cells are destroyed quickly in response to chemotherapy or radiation. As tumor cells die, nucleic acids and intracellular metabolites are released and exceed the excretory capacity of the kidneys. Nucleic acids are converted to uric acid in the liver and may crystallize leading to obstruction of the kidneys and acute renal failure.

18. Complications of Cancer Treatment • Graft versus host disease (GVHD): immune response resulting from disparities in the match between donor and recipient bone marrow. The donor white cells perceive the child’s body as foreign material to be attacked and destroyed. Graft versus host disease is usually restricted to certain organs such as the skin, GI tract, liver, and other organs. The symptoms of GVHD can be minimal or life-threatening and include skin rash beginning on the hands and feet, spreading to other parts of the body, diarrhea, jaundice and infection. These symptoms are managed with symptomatic support and immunosuppressive drugs.

19. Complications of Cancer Treatment • Hypercalcemia: when large amounts of bone are destroyed by treatments • Hyperleukocytosis: increased WBC count leads to capillary obstruction, micorinfarction, and organ dysfunction • Obstructions: from space-occupying lesions, masses, tumors, catheters • Overwhelming infection: sepsis, septic shock – due to protein malnutrition and other dietary deficiencies and immune suppression • Life-threatening hemorrhages: from DIC, thrombocytopenia, leukocytosis, intracranial bleeding • Death: due to high energy demands and nutrient needs of cancer cells – take over nutrients and O2 supply needed by normal cells to survive

20. Types of Cancers in Children • Leukemia: group of malignant diseases of the bone marrow and lymphatic system. Normal bone marrow elements are replaced by abnormal immature lymphocytes, known as blast cells – most common form of childhood cancer • Acute lymphocytic leukemia: accounts for 80% of all childhood leukemia. Peak incidence occurs between the ages of two and five years old. CNS prophylaxis. • Acute myelogenous leukemia: accounts for 15 to 25% of all childhood leukemia. Prognosis is poorer than for those with ALL.

21. Types of Cancers in Children • Brain tumors: most common solid tumor. Second most common form of childhood cancer. Third leading cause of death in children under 16 years of age. Prognosis varies depending upon the age of he child at diagnosis, pathology and location of the tumor. • Astrocytoma: most common type of CNS tumor in children

22. Types of Cancer in Children • Lymphomas: malignancy that arises from the lymphoid system. Lymphomas are the third most common type of childhood cancer • Hodgkin’s disease: usually originates in a cervical lymph node and spreads to other lymph node regions. Accounts for approximately 5% of childhood malignancies. • Non-Hodgkin’s lymphoma: no single focal origin, malignant cells are rarely localized. Has a rapid onset and presents with widespread involvement

23. Types of Cancer in Children • Neuroblastoma: nervous system tumors arising from adrenal gland or retroperitoneal sympathetic chain (brain, adrenal medulla, pelvis, mediastinum, and sympathetic ganglia) • Fourth most common childhood malignancy • Most common malignant tumor of infancy “silent tumor” – poor prognosis

24. Types of Cancer in Children • Wilm’s Tumor: most common type of renal cancer in children • Usually presents as an abdominal mass. • A large flank mass is usually found in a healthy child by a family member • The mass is present on one side and seldom crossing the midline, as does neuroblastoma

25. Types of Cancer in Children • Bone tumors • Osteogenic sarcoma: tumor of the bone that usually occurs in the growth metaphysis or the end of the long bones • Ewing’s sarcoma: can present in any bone of the skeleton, but is often seen in the bones of the pelvis, tibia, fibula, and femur

26. Types of Cancer in Children • Rhabdomyosarcoma: soft tissue sarcoma arising primarily from the connective tissues of the body, such as fibrous, adipose, or muscle tissue. • Embryonal: most common type. Usually affects infants and young children in the area of the genitourinary tract and the head and neck area. • Alveolar: occurs in the large muscles of the trunk, arms, and legs

27. Types of Cancer in Children • Retinoblastoma: malignant tumor arising from the retina. Seen only in children. Usually found in infants and very young children. Detected by presence of cat’s eye reflex instead of red reflex • Testicular tumor: most common form of cancer in males age 15 - 34

28. Nursing Care of Children with Cancer • Thorough Assessment • History • Manage side effects of treatment • Infection • Hemorrhage and anemia – administer transfusions as ordered • Nausea / vomiting – administer antiemetics • Altered nutrition – monitor daily weight, strict I&O • Mucosal ulceration – offer bland, moist soft diet, sot toothbrush • Neurologic problems – warn parents of somnolence syndrome • Hemorrhagic cystitis – provide adequate hydration • Alopecia • Steroid effects

29. Nursing Care of Children with Cancer • Nursing care during Bone Marrow Transplantation • Hospitalization 3-6 weeks, isolation • Risk of infection • Numerous procedures • Side effects & complications of cytotoxic treatments • Monitor for graft vs. host disease GVHD & treat • Monitor skin breakdown, wound healing • Sensitive & supportive attitude

30. Nursing Care for Children with Cancer • Prepare for procedures • IV’s • Labs, imaging studies • Bone marrow studies • Lumbar puncture • Surgery • Conscious/unconscious sedation • EMLA cream • Emotional support

31. Nursing Care of Children with Cancer • Pain Management • Opoids • NSAIDs • Health promotion • Dental care • Immunizations • Nutrition • School • Discipline • Vision & hearing screenings

32. Nursing Care of Children with Cancer • Family education • Home care • Referrals • Cessation of therapy • Assess for delayed growth, secondary malignancies, body system disturbances • Follow-up care

33. Questions?