CHAPTER 29

THE CHILD WITH CANCER

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Critical Thinking: Adolescent with Leukemia
Case Study: Teen with Ewings Sarcoma
Media Links: Pediatric Cancer Support and Resources
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Figure 291 Percentage of primary tumors by site of origin for different age groups.
Figure 292 A proto-oncogene normally regulates cellular growth and development.
Figure 293 Computed tomography (CT) can be a frightening procedure for children.
Figure 2913 Approximately 1,700 children under the age of 14 years are diagnosed annually as
having tumors of the brain and central nervous system.
Figure 2916 Lymph nodes and organs affected in Hodgkin disease in children.
Figure 2917 Rhabdomyosarcoma is characterized by ptosis and swelling.

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Figure 2918 Retinoblastoma is characterized by leukokoria, a white reflection in the pupil.

Table 294 Selected Diagnostic Tests for Childhood Ce7 Diagnostic Tests for Ne8 National
Wilms Tumor Study Staging System
Table 2910 St. Jude Childrens 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 childs 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

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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 291)
Etiology Is Variable
Alterations in cellular growth (Figure 292)
Single or combination of factors

External stimuli

Innate immune system and gene abnormalities

Chromosomal abnormalities

Manifestations
Vary by type and location

Pain

Cachexia

Anemia

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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.

CONCEPTS FOR LECTURE

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

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spiritual needs should be included in the plan of care for the child and family.
POWERPOINT LECTURE SLIDES
Diagnostic Tests (Table 294)
Complete blood count and differential
Bone marrow aspiration
Bone marrow biopsy
Lumbar puncture
Radiographic examination
MRI
CT (Figure 293)
Ultrasound
Tumor biopsy
Clinical Therapy
Child managed by pediatric oncologist
Therapy may be singular or a combination of treatments

Surgery

Chemotherapy

Radiation

Biotherapy

HSCT

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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.

CONCEPTS FOR LECTURE

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

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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.
POWERPOINT LECTURE SLIDES
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

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Spinal cord compression

Increased ICP

Brain herniation

Seizures

Hepatomegaly

Gastrointestinal obstruction

Cardiac and respiratory complications

SVC syndrome

LEARNING OUTCOME 4
Recognize the most common solid tumors in children, describe their treatment, and plan
comprehensive nursing care.

CONCEPTS FOR LECTURE

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

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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. Ewings sarcoma is similar, but involves a
smaller, round cell tumor of the diaphyseal portion of the long bones.
POWERPOINT LECTURE SLIDES
Solid Tumors
Brain and central nervous system (Figure 2913)

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 297)

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 Surgical
Chemotherapy
Radiation
HSCT
Wilms tumor

Define

Treatment based on stage (Table 298)

Requires surgical removal
Radiation
Chemotherapy

Bone tumors (osteosarcomas)

Definition

Treatment
Surgery required
Chemotherapy
Radiation

Ewings sarcoma

Similar to osteosarcoma

LEARNING OUTCOME 5

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

CONCEPTS FOR LECTURE

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.
POWERPOINT LECTURE SLIDES
Leukemia
Most commonly diagnosed malignancy in children under 14
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 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

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LEARNING OUTCOME 6
Recognize the most common soft tissue tumors in children, describe their treatment, and plan
comprehensive care.

CONCEPTS FOR LECTURE

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.

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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.
POWERPOINT LECTURE SLIDES
Soft Tissue Tumors
Hodgkin disease

Definition (Figure 2916)

Treatment based on staging

Outpatient setting
Chemotherapy

Non-Hodgkin lymphoma

Definition

Three types

Treatment tailored to stage (Table 2910)

Stages I and II treat with drugs
Stages III and IV treat with additional drugs and longer period

Rhabdomyosarcoma

Definition

Locations (Figure 2917)

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Treatment
Surgical when possible
Wide-field radiation
Chemotherapy

Retinoblastoma

Definition (Figure 2918)

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

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

CONCEPTS FOR LECTURE

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 childs follow-up care.
POWERPOINT LECTURE SLIDES
Psychologic and Physiologic Problems of Cancer Survival
Cancer affects all areas of function

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 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
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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.

CONCEPTS FOR LECTURE

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.
POWERPOINT LECTURE SLIDES
Collaboration to Provide Family-Centered Care
Team meetings

Include family

Include child when appropriate

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 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

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