Pediatric Cancer & Leukemia

December 4, 2007

Pediatric Oncology

Acute leukemia Brain tumors Lymphoma Neuroblastoma Wilm’s tumor Rhabdomyosarcoma Retinoblastoma Osteosarcoma Ewing’s sarcoma

What is Leukemia?

Most common childhood malignancy

Acute lymphoblastic leukemia (ALL)

Acute nonlymphoblastic leukemia (ANLL) Acute myelogenous

leukemia (AML)

Brain Tumors

2nd most common type of cancer

1200 US cases diagnosed/year

Described in terms of: Metastasis (M stage) Size of tumor (T stage)

Brain Tumors

Terminal to curable

Neuropsychological impact varies based on: Location, size, tumor

type Type of treatment Disease of complications Patient factors Social factors

Medical Treatment

Radiation Chemotherapy Surgery

Most cancers considered CURED if no relapse in 5 years.

Bone Marrow Transplantation

Aggressive treatment for malignancies Give near-lethal doses

of chemotherapy or radiation

Replace dead cells with transplanted healthy cells

Autologous vs. Allogenic

Stages of BMT

Donor search & initial evaluation

Preparative treatment

Bone marrow infusion

Stages of BMT

Severe neutropenia

Engraftment Graft-versus-Host

disease

Follow-up

Phases of Cancer

Diagnosis Initiation of treatment Remission or illness stabilization Completion of medical therapy Long-term survival and cue vs. Relapse

or deterioration Terminal illness & death Post-death adjustment of family

Diagnosis

Address emotional reaction

Evaluate family understanding

Determine financial resources Financial Social

Diagnosis

Communication with others What to tell the child?

1. Go slowly

2. Encourage questions

3. Convey hope

4. Establish trust

5. Gauge details to developmental ability

Treatment

Disruption of life Complex treatment

schedules Feeling poorly Reaction of others Maintain contact with

school

Treatment

Coping with acute & chronic pain Bone marrow aspirations (BMA) & lumbar

punctures (LP) Distraction, relaxation, hypnosis

Anticipatory nausea & vomiting Classical conditioning Relaxation, imagery, distraction

Treatment

Parents need to feel some control during the treatment process Helplessness Hopelessness

Don’t forget the siblings!

Suggestions for parents Give them time too Choose caregivers

carefully Set limits on gifts Allow them to “help

out” Answer questions

Coping Strategies

Adaptive Positive reframing Acceptance Social support Maintaining

objectivity Active involvement

Maladaptive Denial Helplessness Cognitive escape Behavioral escape

Remission or Stabilization

Maintenance chemotherapy

Return to school Social re-entry concerns Academic performance

Role of doubts and fears

Completion of Treatment

Emotional reliance on treatment

Weaning from frequent appointments

Completion of Treatment

Marital stress

Difficulty with discipline

Long-term Survival & Care

Learning & memory problems

Endocrine dysfunction

Emotional outcomes

Relapse & Recurrence

Occurs in 40-50% of pediatric oncology patients

May be harder emotionally than initial diagnosis

Re-learn basic info Experimental treatments, etc.

Terminal Illness & Death

Communication issues What do children know about “death?”

What do children fear about “death?”

How can parents discuss the child’s own death with him/her?

Children’s Understanding of Death

Ages 3-5 Some understanding

Ages 6-8 Understand that death is irrevocable & universal

Ages 9+ Recognize cause of death; have mature conception of death

Common Fears of Death

Fear of pain Fear of being alone Fear of the unknown Fear of disappointing

parents Fear of leaving

others behind

Parents Talking to their Children about Death

Concerns Will it lead to difficulty coping after the

child’s death? Will it interfere with the child’s sense of

hope? Will it impact the child’s medical care?

Parents Talking to their Children about Death

What can they say? Answer questions honestly Give the child permission to cry, be angry,

or be sad Tell children that adults do not understand

death Reassure child that loss is never complete

Preparing for Death

Anticipatory grieving

Preparation for death Hospice care

After child’s death…

Mourning

Support groups