The Child With Cancer

Review of Cancer
A neoplasm is any tumor that arise from new , abnormal growth. A tumor may be
either beign or malignant. The distinguishing feature of cancer is its ablity to invade
surrounding tissue and spread to distant sites. Cancel celss spread in one of two
ways : (1) by invasion , in which cells grown in unrestricted , disorderly fashion at
the site of origin; and (2) by metastasis, in which the cells grow in sites other than
the site of the primary cancer. The cancerous cells grow progressively . The cells
have lost the ability to perform their intended functions becaouse changes in the
cells deoxyribonucleic acid (DNA) cause wrong information to be transmitted. As
the cancerous cells continue to proliferate, they crowd out normal cells and
compress vascular structures and vital organs , which results in symptoms.
Tumor staging is based on the results of diagnostic studies and, in some cases,
surgical examination. Stagig describes the extent of disease locally , regionally, and
systematically and guides the therapy for most solid tumors. Each tumor has its
own specific system of staging , which assist in determining treatment and
prognosis.
The cause of most childhood cancers is unknown. One underlying cause of cancer is
genetic. Alterations in normal DNA occur that predispose the child to the
development of cancer. A small percentage of cancers are associated with an
inherited predisposition related to chromosomal abnormalities ( Gurney and Bondy,
2004). A second, more controversial hypothesis contends that cancer develops as a
result of failure of the immune system to distinguish between normal and abnormal
cells. Inactivation of tumor supressorgenes is also thought to be implicated. Known
carcinogens , such as radiation, physical irritation, and chemical irritants, contribute
to development of cancer. Certain environment exposures known to cause cancer in
adults have little correlation with the development of cancer in children.
The cardinal signs of cancer in children differ from those seen in adults. Most adults
cancers are carcinomas, and more screening tools are available to assist with their
early detection. The difficultyin diagnosing cancer in children is that symptoms
resemble those of common childhood illnesses. Children are not often not brought
for medical care until obvious signs and symptoms are present. Primary care
providers are understandably reluctant to think about cancer as the cause of childs
illness.
The Child With Cancer
Cancer in children is often difficult to diagnose, and health care providers must be
aware of the clinical manifestations that should raise the suspicion of cancer. The
signs and symptoms depend of the type of tumor , the extent of disease, and the
childs age. Testing, diagnosis and initation of therapy may occur within a very short
period. The diagnosis of cancer can be devastating to both child and the family. The
nurse becomes the informational lifeline for the child and the family as they go
through the treatment process.

Incidence
Cancer is uncommon in children; nevertheless , pediatric cancer is the second
leading cause of death in childhood, after unintentional injuries, and is the leading
cause of death from diseae. Childhood cancer represents only approximately 1% of
all new cancer diagnosed annually (Gurney and Bond, 2004). Treatment challenges
include minimizing treatment related side effects while maintaining the childs
normal growth and development.
Childhood cancer and Its Treatment
Children with cancer are treated in multidisciplinary setting. Pediatric oncology
nurses play a prominent role in the care of children with cancer and their faimlies.
They support and educate the children and the families as they move through a
stressfull process. Pediatric oncology nurses are challenged and an abilty to provide
the physocological support required by the child and the family. Working with
children with cancer can be an emotional experience. The nurse in this setting must
have a support system and be aware of personal limitations and therapeutic
relationship boundaries ( Hawes, 2005).
A great deal of research has been done over the past 30 years to improve the
outcomes for children with cancer. Current survival rates are attributed to
cooperative , systematic research through the childrens oncology group (COP) and
The International Society of Pediatric Oncology. Eaxh group meets twice a year to
develop new protocols and monitor the progress of current protocols; subgroup
meet as needed throughout the year . Protocols direct when drugs are to be given,
how frequently , and in what dosages , and which diagnostic and follow up studies
are to be performed. Research has shown that children have better outcomes if they
are treated by scientifically derived protocol.
Because of the efforts of cooperative pediatric clinical trials, approximately 74% of
children diagnosed with cancer will survive 5 years or longer after their diagnosis
( Gurney and BOndy ,2004). More than 270.000 survivors of childhood cancer are
estimated to be living in the United States today ( American Cancaer Society ,
2003) . The marked improvement in childhood cancer survival rates has placed
renewed emphasis on the importance of identyifing the long term sequel of cancer
treatment in children and initiating timely intervention (Friedman & Meadows,
2002).
Even afer apparently succesfull treatment of cancer in children , the disease may
recur. A recurrence may occur shortly after therapy has been completed or years
later. A second tumor may represent a new (or second) malignancy. Reccurence
represents the failure to cure the intial disease, whereas a second cancer is likely
result of the intialtreatmet. For example, some children with acute lymphocytic
leukemia (ALL) develop acute myelocytic leukemia (AML) after therapy is complete.
Brain tumor may develop in a small number of children with ALL who were treate
with radiato to their central nervous system (CNS).
Therapeutic Management

Chemotherapy, surgery, and radiation therapy are the primary treatment modalities
for children with cancer. Hematopoetic stem cell transplantation (HSCT) and biologic
response modifiers are reserved for a specific subpopulaion of children with cancer.
Chemotherapy
Chemotherapy is the use of drugs ( antineoplastic agents) to kill cancer cells.
Different of drug known individually to be active against the specific disease are
used. Tumor possess the ability to develop resistance to chemotherapy agents, so a
variety of active drugs are frequently used. Chemotherap may be given orally,
intravenously, intramuscularly, subcutaneously, or intrathecally (through the spinal
coloumn). Depending on the protocol , a child may be hospitalized for
chemotherapy , receive it on outpatient basis, or be trated at home.
The side effects of chemotherapeutic agents represent challenges to caregivers.
Chemotherapy nonselectively kills rapidly dividing cells. The cells most often
affected include cells of the hematopoietic system , gastrointestinal (GI) tract, and
integumentary system.
The bone marrow cells are one of the rapidly proliferating tissues adversely affected
by many chemotherapy agents. Bone marrow production may become suppressed,
resulting in neutropenia, anemia, and thrombocytopenia. The nadir the time of the
greatest bone marrow suppression generally occurs 7 to 10 days after
chemotherapy administration , depending on the specific agent used. The greatest
concern during the periof of bone marrow suppression is infection.
Neutropenia places the child with cancer at risk for the development of
opportunistic infections. Opportunistic infections are caused by nonpathogenic
bacteria and fugi that, because of compromised immunity, may invade and cause
infection . Bacteria generally presents on the skin and within the gut, may invade
the bloodstream through a break in the skin, leading a life threatening infection. In
the presence of markedly decreased white blood cells (WBCs), the usual
inflammatory response (erythema, edema, swelling) indicative of an infection is not
present. Fever is frequently the only indication of infection. Health care providers
and families must remain acutely aware of elevated body temperature and breaks
in the skin during period of neutropenia.
The GI tract is affected in a number of ways. Chemotherapy represents a noxious
stimulus that triggers nausea and vomiting. The treatment of nausea and vomiting
was revolutionized in1992 with the release of a class of nonsedating antiemetic
drugs called 5-HT3 serotonin antagonists. These drugs include ondansetron
(zolfran), granisetron (Kytrill), and dolastreon (anzemet). They have been more
affective in combating chemotherapy induced nausea and vomiting than earlier
antiemetics.
Anorexia is associated with nausea and a change in taste experienced by some
peole in sresponse to certain chemotherapeutic agents. Some children use anorexia
as a way to exert what little control they have left after the diagnosis.

Certain chemotherapeutic agents cause sloughing of the mucosal tissue of the GI

tract, leading to the development of mucositis and esophagitis. These conditions
can be painful and can be contribute to poor nutrition. Bacteria and yeasts, present
as part of the normal digestive process in the mouth and gut, may cross the open
skin and be absorbed into the bloodstream, The presence of breaks in the
integument may lead to bacterial infections of the blood.
Decreased activity, pain medication, and poor oral intake may contribute to the
development of constipation. Certin the chemotherapeutic agents may also
contribute to constipation . Passage of hard stool may cause abrasion of the delicate
mucous membrane of the rectum. The stool is loaded with microorganism as part of
the digestive process. Again, the presence of breaks in the integument may lead to
bacterial infections of the blood.
Hair loss has tremendous psychological effect, especially on the school age and
adolescent population. Some chemotherapeutic agents do not produce hair loss, but
most do. Treatment related fatigue , common in adult cancer patients, is poorly
reported in the child and adolescent population, although an increasing body has
inditified and decribed fatigue in adolescent with cancer (Erickson, 2004) . Other
side effects are spesdific to the agent being used as well as the dose.
Nurses administering chemotherapeutic agents should have evidence of special
chemotherapy training by instituition in which they work. No nationally recognized
chemotherapy administration cerctification is currently available. Nursing
responsibilitis and precautions related to chemotherapy administration are detailed
in box 24-2.
Surgery
Surgery is frequently part of cancer therapy fior children . the surgery may be
limited to a biopsy or be used to remove a solid tumor mass. The purpose of biopsy
is to obtain a small piece of the tumor for microscopic examination. Examination of
the tissue by a pathologist confirms the tumor type and influences therapy
decisions. Surgery may also be used to debulk or resect a solid tumor mass. In
some disease, the tumor cannot be resected at the beginning of therapy. After the
child has received some chemotherapy, the mass may decrease in size and less
extenseive surgical procedure may be performed.
A central venous catheter is frequentl placed during the initial surgical procedure to
faicilitate chemotherapt administration. A central venous catheter is a central line
placed to provide easy acsess to venous system; the proximal part of the catheter
ends in the large vein just above the heart, the superior vena cava. Three types of
central venous catheter are availabl .In an external catheter , the distal portion exist
site where the skin will adhere and hold the catheter in place. In an implanted
catheter, the distal oprtion ends in a well , whicih is placed in the subcutaneous
tissue, frequently in the anterior chest wall. A percutaneously ( peripherally)
inserted central catheter (PICC) is not surgically placed. The proximal tip ends in the
same large vein as other catheters , but the distal portion is not tunneled. The

catheter is frequently inserted in antecubital fossa by a technique smiliar to

placement of peripheral intravenous (IV) catheter.