chaper 29 child with cancer

CHAPTER 29

THE CHILD WITH CANCER

Resource Library

Student Resource Site

Audio Glossary

NCLEX Review

Critical Thinking: Adolescent with Leukemia

Case Study: Teen with Ewing’s Sarcoma

Media Links: Pediatric Cancer Support and Resources

Media Link Applications

Videos and Animations: Genetics of Cancer; Leukemia; Nursing in Action: Central Venous

Catheter Care

Pediatric Dosage Calculations

Image Library

Figure 29–1 Percentage of primary tumors by site of origin for different age groups.

Figure 29–2 A proto-oncogene normally regulates cellular growth and development.

Figure 29–3 Computed tomography (CT) can be a frightening procedure for children.

Figure 29–13 Approximately 1,700 children under the age of 14 years are diagnosed annually

as having tumors of the brain and central nervous system.

Figure 29–16 Lymph nodes and organs affected in Hodgkin disease in children.

Figure 29–17 Rhabdomyosarcoma is characterized by ptosis and swelling.

Copyright 2014 by Pearson Education Inc.

Figure 29–18 Retinoblastoma is characterized by leukokoria, a white reflection in the pupil.

Table 29–4 Selected Diagnostic Tests for Childhood Ce–7 Diagnostic Tests for Ne–8 National

Wilms Tumor Study Staging System

Table 29–10 St. Jude Children’s Research Hospital Staging CeNon-Hodgkin Lymphoma

LEARNING OUTCOME 1

Describe the incidence, known etiologies, and common clinical manifestations of cancer.

CONCEPTS FOR LECTURE

1. Cancers in children often have a different etiology than those of adults. Adult cancers are

epithelial in origin and in children they are nonepithelial or embryonal. Adult cancers are

slow growing; childhood cancers are fast growing. A major physiologic difference between

adults and children involves the immune system and how well it functions. During the first

month of a child’s life, the nonspecific immune response is immature; it is also impaired in

premature and SGA infants. The specific immune response is also below adult levels.

2. In the United States, cancer is diagnosed in approximately 11,000 children, and about 1,500

children die from cancer annually. In children under 15 years of age, cancer is the leading

cause of disease-related death, and it is the second leading cause of death overall followed by

unintentional injury. Survival rates vary for different types of cancer.

3. The etiology of cancer is variable. Alterations in cellular growth occur in response to

external and internal stimuli. Cancer may be caused by one or a combination of three factors:

external stimuli, innate immune system and gene abnormalities, and chromosomal


abnormalities.

4. Clinical manifestations vary by the type of cancer and location. Many of the symptoms of

cancer are typical of common childhood illnesses and a delay in diagnosis may occur.

Common presenting symptoms are pain, cachexia, anemia, infection, bruising, neurologic

symptoms, and a palpable mass.

POWERPOINT LECTURE SLIDES

Incidence of Cancer in Childhood

Approximately 11,000 children under the age of 15 diagnosed annually

Under age 15, cancer is leading cause of disease-related death

Approximately 1,500 children die annually of cancer

Types of tumors vary by age and affect survival rate (Figure 29–1)

Etiology Is Variable

Alterations in cellular growth (Figure 29–2)

Single or combination of factors

° External stimuli

° Innate immune system and gene abnormalities

° Chromosomal abnormalities

Manifestations

Vary by type and location

° Pain


° Cachexia

° Anemia

° Infections

° Bruising

° Neurologic

° Palpable mass

LEARNING OUTCOME 2

Synthesize information about diagnostic tests and clinical therapy for cancer to plan

comprehensive care for children undergoing these procedures.


1. The diagnostic tests most commonly used for children with cancer include complete blood

count (CBC), bone marrow aspiration (BMA) and bone marrow biopsy (BMBX), lumbar

puncture (LP), radiographic examination, magnetic resonance imaging (MRI), computed

tomography (CT), ultrasound, tumor markers, and biopsy of the tumor. Additional testing

may be done when certain cancers are involved.

2. Clinical therapy is extremely complex and is managed by a specialist in pediatric oncology.

Cancer may be treated with one therapy or a combination of therapies and the goal may be

either curative or palliative.

3. Options for clinical therapy treatment may be surgery, chemotherapy, radiation, biotherapy,


hematopoietic stem cell transplantation (HSCT), complementary therapies, and palliative

care.

4. The care plan for a child with cancer will vary based on the type of cancer and clinical

therapy treatment plan. Infection control, pain, nutrition, growth and development, and

emotional and spiritual needs should be included in the plan of care for the child and family.


Diagnostic Tests (Table 29–4)

Complete blood count and differential

Bone marrow aspiration

Bone marrow biopsy

Lumbar puncture

Radiographic examination

MRI

CT (Figure 29–3)

Ultrasound

Tumor biopsy

Clinical Therapy

Child managed by pediatric oncologist

Therapy may be singular or a combination of treatments

° Surgery


° Chemotherapy

° Radiation

° Biotherapy

° HSCT

° Complementary therapies

° Palliative care

Nursing Care Plan

Based on type of cancer and therapy

° Infection control

° Pain

° Nutrition

° Growth and development

° Emotional needs

° Spiritual needs

LEARNING OUTCOME 3

Integrate information about oncologic emergencies into plans for monitoring all children with

cancer.



1. Oncologic emergencies result from the cancer itself or as a side effect of treatment. The

emergencies can be classified into three groups: metabolic, hematologic, and those involving

space-occupying lesions. The most common emergencies are tumor lysis, septic shock, brain

herniation, spinal cord compression, and superior vena cava compression from a mass.

2. Metabolic emergencies result from the lysis of tumor cells. Septic shock may occur with

changes in the metabolic system. The final type of metabolic emergency is hypercalcemia

due to bone destruction. Treatment is based on the metabolic occurrence and reversal or

acute management as indicated by signs, symptoms, and lab data.

3. Hematologic emergencies result from bone marrow suppression or infiltration of brain and

respiratory tissue with high numbers of leukemic blast cells. This may become life

threatening. Treatment involves infusion of packed red blood cells, platelet transfusion,

vitamin K, and fresh frozen plasma.

4. Space-occupying lesions are tumors with extensive growth that may result in spinal cord

compression, increased intracranial pressure, brain herniation, seizures, massive

hepatomegaly, cardiac and respiratory complications, and superior vena cava syndrome.

Treatment involves radiation therapy, chemotherapy, and corticosteroids.


Three Types of Oncologic Emergencies

Metabolic

° Tumor lysis syndrome

° Septic shock


° Hypercalcemia

Hematologic

° Caused by bone marrow suppression

° Require transfusion and careful RBC and WBC assessment

Space-occupying lesions: tumors with extensive growth

o Spinal cord compression

o Increased ICP

o Brain herniation

o Seizures

o Hepatomegaly

o Gastrointestinal obstruction

o Cardiac and respiratory complications

o SVC syndrome

LEARNING OUTCOME 4

Recognize the most common solid tumors in children, describe their treatment, and plan

comprehensive nursing care.


1. Brain and central nervous system tumors are the most commonly occurring solid tumors in


children and the second most common malignancy, after leukemia. Treatment depends on

the type of tumor. Surgery is a common treatment, and might be done to debulk or excise the

tumor. Radiation is commonly used in treatment following surgery. Chemotherapy may be

indicated in some cases.

2. Neuroblastoma is a solid tumor most commonly occurring outside of the cranium of

children. It is the most common tumor in infancy. The stage of the tumor determines the

treatment protocol. Surgical excision followed by chemotherapy is one option.

Chemotherapy and/or radiation may be required prior to removal depending on the location

and size of the tumor. HSCT may be considered in advanced cases of the disease.

3. Wilms tumor (nephroblastoma) is an intrarenal tumor. Wilms tumor has been associated with

congenital anomalies. Treatment requires surgical removal of the tumor. Based on the stage

of the tumor, radiation or chemotherapy may or may not be required.

4. Bone tumors (osteosarcomas) are rare and occur most frequently in adolescent males.

Surgery for removal of affected bone, with either a salvage of limb or amputation, must be

performed. Aggressive chemotherapy after surgery is noted to improve survival rates.

Physical therapy and rehabilitation are necessary postoperatively. Ewing’s sarcoma is

similar, but involves a smaller, round cell tumor of the diaphyseal portion of the long bones.


Solid Tumors

Brain and central nervous system (Figure 29–13)

° Most common malignancy in children, next to leukemia

° Treatment depends on type and location of tumor


° Surgery

° Radiation

° Chemotherapy

Neuroblastoma

° Definition

° Treatment based on protocol (Table 29–7)

– Surgical

– Chemotherapy

– Radiation

– HSCT

Wilms’ tumor

° Define

° Treatment based on stage (Table 29–8)

– Requires surgical removal

– Radiation

– Chemotherapy

Bone tumors (osteosarcomas)

° Definition

° Treatment


– Surgery required

– Chemotherapy

– Radiation

Ewing’s sarcoma

° Similar to osteosarcoma

LEARNING OUTCOME 5

Plan care for children and adolescents of all ages who have a diagnosis of leukemia.


1. Leukemia is the most commonly diagnosed pediatric malignancy in children under 14 years

of age. Leukemia is a cancer of the blood-forming organs and is characterized by a

proliferation of abnormal white blood cells in the body. There are several types of leukemia

depending on the blood cells affected.

2. Nursing management is difficult due to complex multisystem effects of the disease, and the

long period of time required for therapy. Thorough assessments are an ongoing requirement.

Observe for signs of bleeding and infection.

3. Monitor for toxic side effects from chemotherapy and/or tumor cell lysis. Renal function,

nutrition, CNS infiltration, and pain assessment should be completed not more than every 8

hours.

4. Pay special attention to renal status for children receiving cyclophosphamide. Hydration


status and precise calculation of fluid requirements are required. Drug side effects may

necessitate infusion of platelets or packed red blood cells.

5. Bone marrow suppression may require isolation and transmission precautions. Education for

family and child includes careful hand washing and oral care.

6. Nurses play a key role in the long-term multidisciplinary treatment of children with

leukemia.


Leukemia

Most commonly diagnosed malignancy in children under 14

Definition

Nursing Management

Difficult due to multisystem effect

Long period of treatment required

Assessment complete and thorough

° Observe for signs of bleeding

° Observe for signs of infection

Monitor for toxic side effects of chemotherapy or tumor cell lysis

° Renal function

° Special attention for children on cyclophosphamide

Nutrition


CNS infiltration

Pain

Bone marrow suppression

° Isolation and transmission precautions

Child and family coping

Education of family and child

° Careful hand washing

° Prevention of spread of infection

° Oral care

LEARNING OUTCOME 6

Recognize the most common soft tissue tumors in children, describe their treatment, and plan

comprehensive care.


1. Hodgkin disease is a disorder of the lymphoid system. Diagnosis is based on lymph node

biopsy and a staging classification is used to determine disease severity. Treatment is

performed in an outpatient setting unless complications develop that require hospitalization.

Chemotherapy using a four-drug combination has been found to be the most effective drug

treatment.

2. Non-Hodgkin lymphoma has three different types that may present in the pediatric


population. The lymphoma must be staged and the treatment is tailored to the type of cancer

and stage. Stages I and II are treated with drugs and possibly intrathecal medication. Stages

III and IV are treated with additional drugs and for a longer period of time.

3. Rhabdomyosarcoma is a soft tissue cancer that is common in children. It occurs most often

in the muscles around the eyes and neck, and less commonly in other locations. Treatment

includes surgical removal of the tumor when possible. Surgery is followed with wide-field

radiation and chemotherapy.

4. Retinoblastoma is an intraocular malignancy of the retina. Treatment for retinoblastoma may

include removal of the eye (enucleation) when there is permanent retinal damage or failure

to respond to other treatment. Radiation is nearly always used. Chemotherapy is sometimes

used but is often ineffective as the drugs fail to penetrate sufficiently into the eye.

5. Nursing management for soft tissue tumors is similar to solid mass tumors. Physiologic

assessment, psychosocial assessment, and collaboration with family and team members are

important. Assessment and interventions based on potential side effects of therapies and

treatment along with pain management should be priorities.


Soft Tissue Tumors

Hodgkin disease

° Definition (Figure 29–16)

° Treatment based on staging

– Outpatient setting


– Chemotherapy

Non-Hodgkin lymphoma

° Definition

° Three types

° Treatment tailored to stage (Table 29–10)

– Stages I and II treat with drugs

– Stages III and IV treat with additional drugs and longer period

Rhabdomyosarcoma

° Definition

° Locations (Figure 29–17)

° Treatment

– Surgical when possible

– Wide-field radiation

– Chemotherapy

Retinoblastoma

° Definition (Figure 29–18)

° Treatment

– Radiation almost always used

– Chemotherapy sometimes used, but often ineffective


– Removal of eye if other treatment fails

Nursing Management

Similar to other cancers

Physiologic assessment

Psychosocial assessment

Collaboration with family

Collaboration with medical team

Intervention based on assessment and side effects of therapy

.

LEARNING OUTCOME 7

Analyze the impact of cancer survival on children and use this information to plan for ongoing

physiologic and psychosocial care.


1. Children with cancer have a variety of common psychologic and physiologic problems,

regardless of their specific type of cancer. The impact of this experience extends into all

areas of body and life function for the child and family.

2. Therapy for cancer can leave devastating effects on the body, both external and internal.

Surgery can leave external reminders and place some children at risk for other problems.

3. Radiation has long-term effects, such as impairment of growth in various body systems.


Secondary cancers may occur subsequent to the primary cancer and treatment but are of a

different type.

4. Chemotherapy can cause a wide variety of effects, both during and after administration. The

effects may not be noted for years.

5. General long-term management of cancer survival should plan for stress and coping for the

family and child. Issues of concern range from loss of life or limb to ability to pay for

treatment and care afterward. Children surviving cancer require frequent and thorough

physical, physiologic, developmental, and cognitive assessment. Interventions should be

started as soon as possible if any concern arises in the child’s follow-up care.


Psychologic and Physiologic Problems of Cancer Survival

Cancer affects all areas of function

Effects of therapy

° Surgery

– External and internal body changes

° Radiation

– Long-term effects

– Growth

– Secondary cancers

° Chemotherapy


– Effects immediate

– May present years later

Long-term planning

° Family stressors

– Questions regarding outcomes

– Financial concerns

° Frequent follow-up

– Physical

– Physiologic

– Developmental

– Cognitive

– Interventions started as soon as deficit noted

LEARNING OUTCOME 8

Recommend methods for an oncology team including nurses, social workers, psychologists, and

child life specialists to partner with school personnel, children and adolescents, families, and

others to meet the needs of children with cancer.


1. Collaborate with the family to provide family-centered care. Team meetings should include

the family and child if appropriate.

2. Teams providing and planning care for the child with cancer include nurses, primary and


specialty healthcare providers, social workers, case managers, child life therapists, and

psychologists. The team requires a collaborative environment and a team leader to maintain

contact and update team members as needed on changes in the status of the child and family.

3. The child, if school age, will have specific needs regarding communication and involvement

with school activities. The child should be encouraged to maintain active participation in

studies, even if not attending school.

4. Spiritual and emotional needs should be addressed on a regular basis. Encouragement to join

support groups and interact with others to seek support is appropriate.


Collaboration to Provide Family-Centered Care

Team meetings

° Include family

° Include child when appropriate

Team members

° Nurses

° Primary and specialty care providers

° Social workers

° Case managers

° Child life therapist

° Psychologist


For the school-age child

° Encourage maintenance of learning

° Involvement of school appropriate with permission

Spiritual and emotional needs

° Encourage participation in support groups


chaper 29 child with cancer

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