The Child With a Malignancy

1. The Child With a Malignancy Jan Bazner-Chandler CPNP,MSN, CNS, RN

2. Developmental and Biologic Variances • Most childhood cancers arise for embryonic mesodermal germ layer • Involves tissues of: CNS, bone, muscle, endothelial tissue, connective tissue, blood, lymph tissue • Grows in a short period of time • 80% have metastasis at time of diagnosis

3. Assessment • Unusual mass or swelling • Unexplained paleness and loss of energy • Spontaneous bruising • Prolonged, unexplained fever • Headaches in morning • Sudden eye or vision changes • Excessive – rapid weight loss

4. Diagnostic Tests • X-ray • Skeletal survey • CT scan • Ultrasound • MRI • Bone marrow aspiration • CBC with absolute neutrophil count • Urinalysis • Lumbar puncture • Urine catecholamines

5. Treatment Modalities • Determined by: • Type of cancer • Location • Extent of disease

6. Surgical Management • The oldest form of cancer treatment • Surgery plays important role in initial diagnosis: biopsy of primary tumor. • Excision of tumor when possible • Facilitating treatment: insertion of catheters for long-term treatment

7. Radiation Therapy • The use of ionizing radiation to break apart bonds within a cell causing cell damage and death. • External beam therapy accounts for the majority of radiation treatments in children. • Problems: radiation beams cannot distinguish between malignant cells and healthy cells.

8. Chemotherapy • Primary treatment modality used to cure many pediatric cancers. • Chemotherapy is the use of drugs to destroy cancer cells. • The destruction is accomplished by inhibiting cells within the body to divide, which eventually leads to cell death.

9. Chemotherapy • Can be given in addition to another form of therapy such as radiation or surgery. • Drugs may be administered before surgery to reduce size of tumor. • Adjuvant chemotherapy is used after surgery or radiation therapy to prevent relapse.

10. Chemotherapy • Combination chemotherapy is the use of more than one class of drug. • Administering different classes of chemo drugs ensures a greater chance of achieving complete cancer cell destruction and achieving remission.

11. Administration • Chemotherapy can be given by mouth, subcutaneous or intramuscular injections, intravenously, or intrathecally. • Oral route used if drug is well absorbed and non irritating to the GI tract • Sub-q or IM: Slow systemic release • IV push, piggyback or intravenous infusion

12. Goals of Chemotherapy • Reducing the primary tumor size • Destroying cancer cells • Preventing metastases and microscopic spread of the disease

13. Chemotherapy Drugs • Alkylating drug: attack DNA • Antimetabolites: interfere with DNA production • Antitumor antibiotics: interferes with DNA production • Plant alkaloids: prevent cells from dividing • Steroid hormones: slow growth of some cancers

14. Bone Marrow Transplant • HSCT: Hematopoietic Stem Cell Transplant: CHLA has one of the largest program. • The option of HSCT depends on the patients disease, disease status, and general physical condition. • Involves: • Umbilical cord blood • Parent’s stem cells

15. Gene Therapy • Use of gene therapy in the treatment of childhood cancer is promising yet complex and still in early phases of clinical application.

16. Management • Patient / family education • Begins at time of diagnosis • Continues through treatment phases • Maintained in post-survival years • Support if death of child

17. Pain Management • Pain caused by disease • Pain with procedures and treatments • Pain associated with side effects of treatment

18. Pain Management • Pharmacologic • Non-Pharmacologic • Sedation or anesthetic medications • EMLA cream • Conscious sedation

19. Pain Control

20. Immunosuppression and Infection • Children with cancer become immune impaired from a number of causes: • Lymphocyte production is altered • Splenic dysfunction can prevent maturation of blood cells and alteration is inflammatory response. • Cancer therapy can decrease immunoglobulin concentrations.

21. Neutropenia • Significant neutropenia can develop during chemotherapy creating an increased risk of infection in the child with cancer. • Neutropenia occurs when the absolute neutrophil count decreases below 500.

22. Treatment for Neutropenia • Granulocyte colony stimulating factor decreases the duration of neutropenia by stimulating the proliferation of the progenitor cells of the granulocytes, specifically the neutophils. • G-CSF: 5mcg/kg/day given subcutaneous

23. Varicella • If an immunosuppressed child with no history of varicella infection or varicella immunization has direct contact with an individual with chickenpox or shingles, varicella zoster immune globulin should be administered. • Acyclovir IV is used in some cases.

24. Varicella Immunizations • Three months after chemotherapy • Off prednisone • Many will have already had the immunization as a toddler since it is now a required immunization.

25. Central Venous Access Devices • Two decades ago, CVAD were introduced as an integral part of the pediatric oncology patient’s treatment plan. • Used to deliver chemotherapy, blood components, antibiotics, fluids, TPN, medications and blood sampling.

26. CVAD Infection Prevention • Teach family to report signs of catheter infections: fever, chills, swelling, pain, drainage, or erythema. • Aseptic technique for dressing changes and heparin flushing. • Avoid trauma to device • Observe for catheter occlusion

27. Chemotherapy Side Effect • Drugs affect not only the cancer cells but also healthy cells. • Cells most affected are rapidly growing cells such as hair follicles, reproductive system, bone marrow and gastrointestinal tract.

28. Management of Side Effects

29. Malnutrition • Occurs in 8 to 32% of the pediatric oncology population • Nutritional goals focus on maintaining normal growth and development as well as preventing nutritional deficiencies.

30. Nutrition Interventions • Initial nutritional assessment • History of child’s eating habits, food allergies, use of nutritional supplements, base line weight and height measurements. • Enteral feedings at night: preserve intestinal mucosa by keeping it functional

31. Nausea and Vomiting • Most common side effect of cancer treatment. • Chemotherapy-associated vomiting is a reflex controlled by chemoreceptor trigger zone that stimulates the vomiting center in the brain. • Tumor location • Radiation therapy • Anticipatory nausea

32. Interventions • Antiemetics such as Phenothiazines: (Trilafon), (Phenergan)and (Thorazine) block dopamine receptors from stimulating the chemoreceptor trigger zones. • Serotonin-receptor antagonist such as Granisetron (Kytril) and Ondansetron (Zofran) are very effective. (>3 years) • Antihistamines: benadryl • Administer before chemotherapy

33. Mucositis • Progressive, inflammatory, ulcerative condition of the oral and gastric mucosa. • Occurs due to the interruption of cell renewal process of the epithelium leading the mucosal atrophy and ulceration • Thrombocytopenia or physical trauma may lead to bleeding and further mucosal damage. • Neutropenia and poor dental hygiene predisposes the oral mucosa to secondary infection.

34. Assessment / Interventions • Baseline assessment including the oral cavity, teeth, and gingival mucosa. • History of dental exam and use of orthodontic appliances • Meticulous oral care • Mouth rinses • Monitor hydration status

35. Constipation • Assess normal bowel habits • Increase fiber and fluids in diet • Stool softeners / colace • Physical activity • Avoid digital manipulation

36. Diarrhea • Assess for signs of dehydration • Record stool patterns • IV fluids as needed • Low-residue or lactose-free diet • Good hand washing

37. Hair Loss • More important in the older child. • Most patients will experience hair loss within 10 days of induction chemotherapy • Prepare patient for hair loss • Males: shave hair • Females: short hair style – pick out wig – scarf - hat

38. Psychosocial Support • Support groups • Open communication • Daily contact with oncology team • Trusting relationship with nurse

39. Growth and Development • Promote normal G & D • Allow decision making • Establish daily routines • Play therapy • Friends • School attendance or tutor

40. Late Effects of Cancer Therapy • Endocrine: sterility • Thyroid • Cardiovascular • Musculoskeletal • Vision • Hearing • Respiratory • Gastrointestinal • Genitourinary • Hematopoietic

41. Leukemia • Most common malignancy • Cancer of blood or bone marrow characterized by an abnormal proliferation of blood cells, usually white blood cells (leukocytes) • Two types • Acute lymphoblastic leukemia: 78% • Acute Myelogenous leukemia: 15 to 20% • High survival rate

42. Prognosis • Initial WBC most significant • The higher the count the poorer the outcomes • Greater than 100,000 WBC count = poor outcome • Children under 2 years and older than 10 • Girls do better than boys

43. Diagnosis • Peripheral blood smear • Bone marrow analysis • Lumbar puncture

44. Assessment • Pallor and fever • Lethargy • Anorexia • Weight loss • Hemorrhage / petechiae • Hepatomegly / splenomegaly

45. 3 Phase Treatment • Induction: goal is to achieve remission last about a month • Consolidation: most intensive phase of chemotherapy lasts 4 to 8 months • Maintenance: last two to three years • If leukemia cells are detected in bone marrow process is started all over again.

46. Induction Therapy • Goal of therapy is to achieve remission • Leukemia cells are no longer found in the bone marrow samples, the normal cells return and blood counts become normal. • Drugs used: L-asparaginase, vincristine and a steroid (dexamethasone), for high-risk children a fourth drug (daunorbucin) is often used

47. Consolidation Phase • Several drugs are used in combination to prevent remaining leukemia cells from developing resistance. • Drugs include: methotrexate and 6-mercaptopurine, vincristine and prednisone

48. Maintenance • If leukemia continues to be in remission maintenance therapy can be started. • Two drugs: vincristine and steroids over a brief period every 4 to 8 weeks. • Duration of total therapy 2 to 3 years.

49. CNS Therapy • CNS prophylaxis is initiated at diagnosis and is used to reduce the risk for CNS disease. • Preventive CNS is based on the premise that the CNS provides a sanctuary site for leukemic cells that are undetected at diagnosis and reside protected from the action of systemic therapy by the brain blood barrier.

50. Multidisciplinary Interventions • Assess for infection • Monitor blood values • I & O / nutrition • Complications of chemotherapy • Good hand washing • Aseptic technique for blood draws