The Child with Cancer

Chapter 36

Christine Limann Dyer, RN, BSAPHON certified

Cancer in Children• Childhood cancer is the second

leading cause of death in children ages 1 to 14 years

• Incidence approximately 129 per million

• Leukemia most common pediatric cancer (Acute lymphoblastic leukemia “A.L.L.”)

• Next most common are brain tumors and lymphoma

• Greatly improved prognosis in past 30 years

As recently as the 1960’s childhood cancer was a uniformly fatal disease.

By the year 2000, the 5-year disease-free survival rate for childhood cancer is greater than 75% (Reaman, 2002.)

Diagnostic evaluation

– Labs

– Biopsy

– Imaging studies

– Review of symptoms, physical exam

Ewing's Sarcoma

Child with Leukemia Undergoing Bone Marrow Aspiration

The definitive test for diagnosis of leukemia

Etiologic Factors

• Genetic basis for some types– Wilms tumor, retinoblastoma,

neuroblastoma

• Chromosome abnormalities– Down syndrome—leukemia

• Immunodeficient child more likely to develop various cancers

• Environmental carcinogens

• Drug exposure as risk for cancer

Modes of Therapy

• Surgery• Chemotherapy• Radiation therapy• Biologic response

modifiers (BRMs)• Bone marrow

transplantation

Nursing priority: Do not remove skin markings for radiation.

Leukemias

• Most common form of childhood cancer• Peak onset between 2 and 6 years old• a broad group of malignant diseases of bone marrow and

lymphatic system• Leukemia is an unrestricted proliferation of immature

WBCs in the blood-forming tissues of the body• Liver and spleen most severely affected organs• Although leukemia is an overproduction of WBCs, often

acute form causes low leukocyte count• Cellular destruction takes place by infiltration and

subsequent competition for metabolic elements

Lymphomas

• Hodgkin disease– More prevalent in 15 to 19 year olds

• Neoplastic disease originating in lymphoid system• Often metastasizes to spleen, liver, bone marrow, lungs, and other tissues

• Non-Hodgkin lymphoma (NHL)– More prevalent in children younger than 14 years

• Approximately 60% pediatric lymphomas as NHL• Clinical appearance

– Disease usually diffuse rather than nodular– Cell type undifferentiated or poorly differentiated– Dissemination occurs early, often, and rapidly– Mediastinal involvement and invasion of meninges

Areas of Lymphadenopathy and Organ Involvement in Hodgkin Disease

CNS TUMORS

• Brain tumors and neuroblastomas are derived from neural tissue

• Account for approximately 20% of childhood cancers

• Tumors are difficult to treat, with poor survival rates

Diagnostic Evaluation

• Signs and symptoms are related to anatomic location, size, and child’s age

• Presenting clinical signs

• Neurologic evaluation

• MRI, CT, EEG, LP

• Histologic diagnosis via surgery

Neuroblastoma

• The most common malignant extracranial solid tumor of childhood

• Majority of tumors develop in the adrenal gland or retroperitoneal sympathetic chain

• Other sites: head, neck, chest, pelvis

• Metastasis may have already occurred before diagnosis is made

Bone Tumors

• Osteosarcoma and Ewing sarcoma account for 85% of all primary malignant bone tumors in children

• Femur most common site• Occur more commonly in

males, with highest incidence during accelerated growth rate of adolescence

Rhabdomyosarcoma

• Malignant neoplasm originating from undifferentiated mesenchymal cells in muscle, tendon, bursa, and fascia or in fibrous, connective, lymphatic, or vascular tissue

• Name reflects tissue of origin– Myosarcoma (myo—muscle)

– Rhabdomyosarcoma (rhabdo—striated muscle)

Wilms Tumor

• Also called nephroblastoma

• Malignant renal and intraabdominal tumor of childhood

• Three times more common in African-American children

• Peak age of diagnosis is 3 years

• More frequent in males

Do not palpate the abdomen, it may disseminate cancer cells to other sites (Jakubik & Selekman, 2006).

Retinoblastoma

• Congenital malignant tumor; arises from the retina

– 60% are nonhereditary and unilateral– 15% are hereditary and unilateral– 25% are hereditary and bilateral

• Cat’s-eye reflex—most common sign

• Strabismus—second most common sign

• Red, painful eye, often with glaucoma

• Blindness—late sign

Testicular Tumors

• Tumors not common, but those appearing in adolescence are generally malignant

• Most common form of cancer in males from ages 15 to 44 years

• Treatment: orchiectomy, followed by chemotherapy and/or radiation depending on metastasis

• Nursing considerations• Importance of testicular self-examination

Nursing Considerations

– Prepare child and family for procedures

– Pain management

– Nausea prevention

– Prevent complication of myelosuppression

– Prevention of infection

-hand washing, reverse isolation

- Central Line placement for chemotherapy

Nursing Considerations

• Preoperative preparation is crucial

• Support during adjustment to concept of amputation, surgical resection

• Body image concerns—issues of adolescents

• Pain management– Phantom limb pain

rotationplasty

Managing Side Effects of Cancer Treatments

• Infection/neutropenia• Hemorrhage• Anemia• Nausea and vomiting• Altered nutrition• Mucosal ulceration• Neurologic problems • Hemorrhagic cystitis• Alopecia• Steroid effects

– Moon face– Mood swings

Pain Management

• Oral or IV dosing preferred

• Appropriate dosage based on body weight

• Titrated to increase analgesia and minimize side effects

Family Education

• “Cancer quackery”

• Communicating about feelings of depression, helplessness, and hopelessness

• Home care

• Support for siblings and family

• Create memory box if appropriate

Death and Dying

• Toddler- Fears death only as an extesion of primary fear of separation from parents

• Preschooler- Perceives death as only a temporary departure

• School age- understands death’s permanence- Is curious about death. May ask direct questions.

• Adolescent- Expresses anger because of inability to be independent or plan future goals. May want to complete projects such as tapes or books for loved ones.

(Jakubik & Selekman, 2006)

References

• Hockenberry, M.J., & Wilson, D. (2007). Wong’s Nursing Care of Infants and Children. (8th Ed.) St. Louis, MO: Mosby Elsevier.

• Jakubik, L. & Selekman, J. (2006). Pediatric Nursing Certification Review. Society of Pediatric Nurses.

• Reaman, G.H. (2002). Pediatric oncology: Current views and outcomes. Pediatric Clinics of North America, 49, 1305-1318.