Cancer

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

Types and Incidence of Cancers

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.

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.

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

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

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

Interventions Radiation therapy Chemotherapy Surgery Bone Marrow and Stem cell transplantation

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

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

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

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.

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

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?

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

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

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

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

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

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.

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.

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.

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

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 

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

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

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

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

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.

Assessment

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

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

Interventions

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

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.

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

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. http://www.candlelighters.org/      American Cancer Society      Make a wish Foundation      Leukemia Society Church and Schools

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.

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

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

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

Diagnostic Tests Abdominal ultrasound CT, MRI Biopsy

Interventions

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

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.

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

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

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

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.

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

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

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

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.

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

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)

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

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 1555 risk for infection, impaired skin integrity, impaired adjustment, disturbed body image, pain

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 1554- 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

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.