1. Cancer

2. Cancer Leading cause of death from disease in children
Almost all childhood cancers involve blood or blood-forming tissues

3. Types and Incidence of Cancers

4. Childhood Cancers
Brain tumors – second leading cause of death from childhood cancer.
Most are cerebellar and brain stem tumors
Lymphomas
Non-Hodgkins lymphomas—one-third present with a mass in the neck or mediastinal area. Also have dyspnea, wheezing, abdominal mass or pain and lymphadenopathy.
Hodgkin’s disease – arises in single lymph node with painless nodal enlargement, followed by extension to adjacent nodes and into spleen, liver, lungs, bone marrow.
Neuroblastoma – malignant tumor arising from sympathetic NS ganglion cells outside the cranium and and can arise from anywhere along the sympathetic nervous system chain. Can also occur in retroperitoneal area, pelvis, neck.

5. Wilms Tumor – solid tumor of kidney.
Rhabdomyosarcoma—malignant tumor of the striated muscle cells.
occur in muscles around eye, head, neck, extremities, GU system.
Retinoblastoma – intraocular malignancy of the retina of eye. Usually unilateral. If bilateral , hereditary. First sign is white pupil.
Others – osteogenic sarcoma/ Ewings sarcoma – tumor of bones of the trunk. Often seen in adolescence growth spurt. Found in distal femur, proximal tibia.

6. Theories of Etiology Intrauterine carcinogens Physical carcinogens
Viruses
Immune defects
Genetics
Discovered gene for leukemia on chromosome 22

7. Warning Signs of Childhood Cancer
C = continual unexplained weight loss H = headaches with vomiting (early morning) I = increased swelling of pain in joints L = lump or mass D = development of whitish appearance in pupil R = recurrent or persistent fevers, night sweats E = excessive bruising or bleeding N = noticeable paleness or tiredness

8. Diagnostic Tests Biopsy Blood Tests CBC Uric Acid
Bone Marrow Aspiration
PET, SPECT
MRI, CT, ultrasound

9. Interventions Radiation therapy Chemotherapy Surgery
Bone Marrow and Stem cell transplantation

10. Radiation Therapy Changes the DNA component of a cell nucleus
The cell cannot replicate which
Inhibits further cell division and growth

11. Effects of Radiation Therapy
Radiation sickness- anorexia, nausea, vomiting
Treated with antiemetics (Zofran or Anzimet). Cool cloth to forehead, provide distraction, accurate I&O.
Fatigue
allow for naps an rest periods (coordinate care), encourage parent to cuddle in bed with child, pillow, blankets, favorite toys
Skin reactions –erythema, tenderness

12. Bone marrow suppression – anemia, neutropenia thrombocytopenia
May be on reverse isolation
Mucositis- inflammation of mucus
membranes mainly the mouth
Offer soft foods, and cold foods.
Frequent mouth care. Lidocaine oral to swish in mouth (older child)
Long term – depends on part of body receiving radiation

13. Chemotherapy
There are several categories of antineoplastic drugs used in treating childhood cancers.
Scheduled at set times and days and by different predetermined routes.
May remain in hospital for few days at first, then later report on specific day for therapy.
Children and Parents must be taught about what to do and not to do during therapy.

14. Review of Common Side Effects of Chemotherapy and Radiation
Bone marrow suppression
Alopecia
Malaise/fatigue
Nausea
Vomiting
Anorexia
Stomatitis
Radiation side effects
Skin reactions
Fatigue
Bone marrow suppression
Nausea
Vomiting
Anorexia
Mucositis

15. Side effects and Toxic Reactions to Chemotherapy
Bone Marrow Suppression – neutropenia, anemia, thrombocytopenia
Place in reverse isolation, keep anyone exposed to a virus away from patient.
Monitor temperature
Should not receive live-virus vaccines
Bleeding Tendency
Apply pressure to puncture site
No contact sports
Check urine and stool for blood
Give stool softeners. WHY?

16. Nausea, vomiting, diarrhea, anorexia
Malaise and fatigue
Encourage video games, movies, etc
Allow visits from friends
Nausea, vomiting, diarrhea, anorexia
Give anti-emetics
Small frequent meals
Monitor for dehydration
Altered mucous membranes
Stomatitis
Rectal ulcerations

17. Side effects of chemotherapy
Renal involvement
Uric acid levels rise as a result of breakdown of cells. The renal tubules causing renal failure.
If kidney affected/damaged- chemo drugs will not be excreted as usual and may limit drugs given.
Body Image changes
Alopecia
Pain Management

18. Nursing Responsibilities Related to Chemotherapy
Know OSHA guidelines for administering antineoplastic agents
Confirm all measurements and calculations
Double-check ordered dosages
Obtain complete blood count within 48 hours of chemotherapy administration
Note white blood cell and platelet levels before chemotherapy begins
Know side effects of chemotherapeutic agents and ways to alleviate these effects

19. Nursing Responsibilities Related to Chemotherapy (Cont’d)
Ensure patency of IV tubing by checking for blood return
Ensure needle placement for implantable infusion device
Give vesicants (agents that can cause tissue necrosis) only through a fresh IV site
Have emergency drugs available

20. Surgery
Curative
Remove the tumor and cancerous tissue
Palliative
Relieve complications due to the cancer

21. Bone Marrow and Stem Cell Transplantation
The goal of therapy is to administer a lethal dose of chemotherapy and radiation therapy that will kill the cancer and then re-supply the body with bone marrow and stem cells to reconstitute immunologic function.
Healthy bone marrow or stem cells are infused into the bloodstream and migrate to the marrow space to replenish the patient’s immunologic function and help kill remaining cancer cells.

22. Types of Transplantations
Syngeneic
bone marrow comes from identical twin
Allogeneic
bone marrow comes from matched sibling (one in four chances) or someone who is histocompatible.
Autologous
own bone marrow. May be harvested at time of remission in preparation for relapse or when bone marrow is free of malignant cells. Also being used so toxic doses of chemotherapy and radiation can be administered and the bone marrow rescued.

23. Procedure
First --All potential donors are typed for HLA (human leukocyte antigen) compatibility.
Collection of bone marrow is a surgical procedure.
The donor undergoes anesthesia for aspiration of the bone marrow
The bone marrow is then processed and frozen
When patient ready - it is infused into the recipient.

24. Side effects of Transplantation
1. Graft-Versus-Host Disease (GVHD) – potentially lethal immunologic response of donor T cells against the tissue of the recipient.
Signs and symptoms – rash, malaise, high fever, diarrhea, liver and spleen enlargement.
Because there is no cure, prevention is essential. Careful tissue typing, irradiation of blood products which helps to inactivate mature T lymphocytes.
2. Rejection of the transplant

25. Post Therapeutic Disabilities
CNS – cognitive disorders, seizures, headaches, coordination problems
Bone – asymmetric growth of bones, easy fractures, scoliosis, kyphosis
CV – cardiomyopathy (pericardial thickening) , pericardial damage
Respiratory – pneumonitis, pulmonary fibrosis
GI – enteritis, bleeding, hepatic fibrosis
Urinary – hemorrhagic cystitis, reflux
Endocrine – decrease in growth, thyroid and gonadal dysfunction
Reproductive – decrease sperm
Dental - caries
Secondary malignancies 

26. Ask Yourself? What is the most common form of childhood cancer?
a. leukemia
b. brain tumors
c. lymphoma
d. osteosarcoma

27. Leukemias A malignancy of the blood forming
tissues/ bone marrow in which normal bone marrow is replaced by
malignant immature WBC’s

28. Etiology and Pathophysiology Leukemia
Most common type of leukemia-- 80% of leukemias in children
The malignant cell involved is the lymphoblast, which is an immature lymphocyte from stem cell.
Highest incidence in children 2-6 yrs of age (white)
Survival rates have improved substantially but are dependent on several factors such as age diagnosis made, initial WBC, and presence of invasion into other organs.
90-95% go into initial remission, 70% survive at least 5 yrs

29. Leukemia
Most common of this type is acute myelogenous leukemia (AML)(20%)
overproliferation of myeloblasts- blast stage is immature
stem cell=myeloblast= basophils, eosinophils, neutophils
overproliferation limits production of RBC's & platelets
usually seen in older children- adolescence- adult
S&S, diagnosis similar to ALL
Remission more difficult than in those with ALL
25% 5 year survival rate-depends on type cell, extent involved, age

30. Pathophysiology of Leukemias
The WBC's are produced so rapidly that immature cells (blast cells) are released into the circulation.
These blast cells are nonfunctional, can't fight infection, and are formed continuously without respect to the body's needs
The blasts cells then invade other organs and interfere with metabolism / function. The production of red blood cells and platelets decreases leading to anemia and thrombocytopenia.

32. Assessment

33. Assessment Signs & Symptoms
Bone marrow Depression results in:
Decrease in mature WBC’s - fever
Decrease RBC’s, Anemia- pallor, lethargy, anorexia
Decreased Platelets/ thrombocytopenia
Increase cell metabolism which deprives cells of nutrients
Enlargement of organs infiltrated with blast cells results in:
Bone pain
Spleenomegaly. Hepatomegaly, Nephromegaly
Lymphadenopathy
CNS infiltration – increased ICP

34. Diagnostic Tests History and Physical Blood Work
Platelet count, Hgb and Hct low
Blast cells appear (where they normally don’t)
Bone Marrow Aspiration
Used to identify the type of WBC involved, therefore, type of leukemia
X-rays of long bones
Show lesions caused by invasion of abnormal cells
Lumbar Puncture – blast cells in the CSF

35. Interventions

36. Chemotherapy
A combination of antineoplastic drugs are given for about a month
A different combination is given for about 2-3 years
Advantages of using a combination of drugs:
Decrease resistance to one drug
Lessening of severe side effects of massive doses of one drug
Breakdown of the tumor cell cycle at multiple sites

37. Chemotherapy Phases
1. Remission induction- most intense treatment. Large doses of antineoplastic drug administered in an effort to destroy as many proliferating cells as possible. Lasts 4-6 wks. About 95% respond.
2. Consolidation- method of destroying leukemic cells in the CNS- for children who have CNS involvement or are high risk. Given Intrathecal.
3. Remission maintenance- drugs given at specific intervals. If remain in remission for 3 yrs, treatment is discontinued. Approx 80% of children who sustain remission for 2-3 yrs continue to remain in remission and appear to be cured.

38. Nursing Care Prevent infection (neutropenia, anemia) Pain Relief
Nausea and vomiting
Mouth discomfort-mucositis / stomatitis
Fatigue
Alopecia
Prevent blood loss-platelet low- nose bleed most common kind of bleed
Support child and family
Assist with referrals to social services, home health agency, chaplain

39. Nursing Care Community Resource http://www.candlelighters.org/
Candlelighters Childhood Cancer Foundation® (CCCF) is a national non-profit membership organization whose mission is to educate, support, serve, and advocate for families of children with cancer, survivors of childhood cancer, and the professionals who care for them.
     American Cancer Society
     Make a wish Foundation
     Leukemia Society
Church and Schools

40. Tumor Lysis Syndrome
Intracellular contents are dumped into the extracellular fluid as cells are lysed, or killed
Intracellular electrolytes overload the kidneys and, if the condition is not monitored and treated, cause kidney failure
Most common in children with leukemias with very high WBCs and in children with non-Hodgkin’s lymphomas, especially when extensive disease is present
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.

41. An embryonic tumor of the kidney.
Wilm’s Tumor
An embryonic tumor
of the kidney.

42. Etiology and Pathophysiology
Cause is unknown
Originates from immature renoblast cells
Tumor is vascular

43. Assessment Palpable abdominal mass Firm and smooth
**The abdomen should not be palpated once the
diagnosis is made. Avoid palpating the tumor mass
during assessment because of the risk of rupturing the
protective capsule. Excessive manipulation can cause
seeding of the tumor and spread of cancerous cells
Abdominal distention
Fever
Fatigue
Late signs
Anemia
Hematuria, dysuria
Hypertension

44. Diagnostic Tests
Abdominal ultrasound
CT, MRI
Biopsy

45. Interventions

46. Interventions Nephrectomy and removal of lymph nodes
Post-op chemotherapy and / or radiation therapy
CT every 6 months for 3 years
Chest x-ray every 3 months for 3 years

47. Nursing Care Pre-op Sign on bed ”Do Not Palpate Abdomen”
Child / Parent teaching
Post-op
Monitor kidney function, Strict I & O
Monitor vital signs—B/P and temperature
Monitor GI function– assess bowel sounds and stool production
NG tube to drainage. Measure abdominal girth.

48. Death and Children Caring for a child who is dying can be one of
the hardest tasks in nursing

49. Understanding of Death
Children under 3
Have no understanding of own impending death
May perceive family anxiety, sadness
Preschool to 5 years
More afraid of separation from parents than of thought of dying. Greatest fear is separation.
Envision death as temporary, and have little of adults’ fear of it
Think of it as a long sleep, not a final process. Nightmares increase.
May feel pain / illness is a punishment for misdeeds or thoughts
May ask questions about death
In long term illness – may simulate adult response with depression, withdrawal, fearfulness, anxiety

50. School Age 5-9
Begin to understand that death is permanent
May think it is something that only happens to adults
Become aware of what is happening to them when their disorder has a fatal prognosis.
Concerns center around fear of pain, fear of being left alone and leaving parents and friends.
May associate death with sleep and may be afraid to go to sleep without someone near them.
May associate death with darkness—want light left on in room

51. Understanding Death
Adolescent, older school age
By age 10 have an adults concept of death, realizing that it is inevitable, universal, and irreversible. Have more understanding than adults realize.
Understand that death is the cessation of life.
Emotional outbursts may reflect anger
View death as fearsome and fascinating (increase in adolescent suicide).
May feel immune to death and deny symptoms for longer than usual because they believe it is impossible that anything serious could happen to them.
Some adolescents consider themselves alienated from their peers and unable to communicate with their parents for emotional support feeling alone in their struggle.

52. Nursing Care Child
Elicit child's understanding of death before discussing
Encourage children to express feelings in own way through play, drawings, or verbalization to promote free expression.
Provide a safe, acceptable outlet for expressions of feelings
Structure care of child to allow child choices and participation in process within constraints of physical condition
Help child maintain independence and control; normal ADL as much as possible (set realistic goals)
Realize that they will go through the stages of dying: denial, bargaining, anger, depression, acceptance

53. Nursing Care Parents
Spend time with family to listen, answer questions, and provide information. Discuss issues with parents before discussing with child.
Provide opportunities for family to express their emotions and deal with their feelings. Parental reactions: continuum of grief process and usually depend on previous experiences with loss, intellectualization.
Reactions may depend on relationship with child and circumstances of illness or injury
Reactions depend on degree of guilt felt by parents-help them sort out

54. Assist parents in expressing fears, concerns, grief to enable them to appropriately support child
Assist parents to understand sibling' possible reactions to terminally ill child
·   Guilt- believing they caused the problem or illness
·  Jealousy- wanting equal attention from parents
·   Anger- feelings of being left behind
Support, enhance parent-child communication, enhance parents' ability to support child
Refer to parent, family support groups- not alone, help focus, open communication, provide information

55. Nursing Care Nurse Nurse needs to care for self.
Care of the caregiver is imperative if the nurse is to provide physical and psychosocial care for families at such a difficult time.
Caring for dying children and their families can be stressful and emotionally demanding.

56. Ewing’s Sarcoma Clinical manifestations Treatment sequence
How does this treatment differ from osteosarcoma?
Why is metastases more of a concern with this cancer?
Ewing's Sarcoma- malignant, small, round cell tumor usually involving the diaphyseal (shaft) portion of the long bones. (femur, pelvis, tibia, fibula, ribs, humerus, scapula, clavical)
pain, edema, fever and elevated WBC count, elevated erythrocyte sedimentation rate, and elevated c-reactive protein. May present with fractures of affected bone resulting from atypical trauma (wouldn't normally cause a broken bone)
1) chemotherapy to reduce the tumor
2) surgical removal of the entire bone or invasive high-dose radiation of the entire bone
3) chemotherapy is always used after initial treatment as undetectable metastases are nearly always present
Undetectable masses are almost always present

57. Clinical manifestations- Treatment sequence-
Rabdomyosarcoma
Clinical manifestations-
Treatment sequence-
Chemotherapeutic agents (VAC)
Rabdomyosarcoma is the most common muscle cancer in children.
What is the sequence of treatment for this cancer? 1) surgery followed by 2)wide-field radiation and chemotherapy
What are the most common chemotherapeutic agents used to treat this type of cancer? Vincristine, Actinomycin, Cyclophosphamide (VAC therapy)

58. Osteosarcoma Clinical manifestations Treatment sequence
Why is the sequence of treatment important?
Disease
Clinical manifestations
Treatment
Osteosarcoma- rare malignant bone tumor usually located in large bone (femur, tibia, or humerus)
Pain and edema to area surrounding malignancy. Pain may refer to hip or back pulmonary metastasis very common
1-Chemotherapy is started before surgery to shrink the tumor
2-surgical removal of tumor (limb-salvage to remove tumor or limb amputation) followed by
3-aggressive chemotherapy to prevent metastasis

59. Nursing Care:
Pre-operative nursing goals for the child diagnosed with cancer-
Disturbed sensory perception
Anticipatory grieving
Risk for infection
Post-operative nursing goals-
Impaired skin integrity
Impaired adjustment- disturbed body image
Pain
Develop 3 pre-operative nursing goals
Disturbed Sensory Perception (visual) related to altered acuity- tumor interfering with visual field and damage to nerves
Anticipatory grieving (family and child) related to potential loss of significant person
Knowledge deficit R/T disease process & treatment modality
Risk for infection- related to inadequate defenses following chemotherapy
What areas of post-operative assessment require priority attention from the nurse? p risk for infection, impaired skin integrity, impaired adjustment, disturbed body image, pain

60. Nursing Care:
What is the rationale for treating some cancers with chemotherapy prior to removal of the tumor?
What specific teaching should the nurse include as priority regarding chemotherapy?
What lab values does the nurse monitor carefully in the client undergoing chemotherapy?
Review care of a child during chemotherapy and radiation therapy.
a. What is the rationale for treating some cancers with chemotherapy
prior to removal of the tumor? P 1554 to reduce the size of the tumor and prevent seeding (spreading or metastasis of the tumor throughout the body
b. What specific teaching should the nurse include as priority regarding
chemotherapy? p the child will have suppressed immune system and must be protected from infection- keep away from individuals or situations in which illnesses may be transmitted or the child may come in contact with pathogens (shopping, zoo, family reunions- public restrooms…)
c. What lab values does the nurse monitor carefully in the client
undergoing chemotherapy? RBC's and WBC's- low white blood cells indicate a need to hold chemotherapy treatment and contact the oncologist

61. Nursing Care:
Prioritize psychosocial needs of the child/family diagnosed with cancer
Develop nursing interventions to assist with stressors that influence the child/family’s response to the diagnosis and treatment of cancer.
What are the priority psychosocial nursing interventions for the client/family with the diagnosis of cancer?
What emotional stressors surround the child/family? fear of loss of the child, guilt if treatment was delayed for any reason, anger at disease process
What financial stressors surround the child/family? Treatment, surgery and numerous hospitalizations & medical care are extremely expensive. Parents may be required to miss work to accommodate treatment plan.
What social stressors surround the child/family? Separation from extended family and friends as they attempt to protect the child from pathogens. Isolation as they begin to grieve the potential loss of a child. Important to get the family into outreach groups and support groups ASAP to assist with these stressors.