1. NUR 264 Pediatrics Julianna Maynor, RN, MSN
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: Chemotherapy Potential 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

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?